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∆∂ÀÃ√™ 8 ñ ¢∂∫∂ªµƒπ√™ 2005
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¶·Ú¿ÁÔÓÙ˜ ∫ÈÓ‰‡ÓÔ˘ - EȉËÌÈÔÏÔÁ›·
9 12 14 16 22
¶·ıÔÊ˘ÛÈÔÏÔÁ›·
KÏÈÓÈΤ˜ MÂϤÙ˜
EӉȷʤÚÔÓ ¶ÂÚÈÛÙ·ÙÈÎfi £Âڷ›· - º¿Ú̷η
¶ÚÔÙÂÈÓfiÌÂÓË µÈ‚ÏÈÔÁÚ·Ê›·
™YNTAKTIKH E¶ITPO¶H ¢È¢ı˘ÓÙ‹˜ ™‡ÓÙ·Í˘ XÂÈÌÒÓ·˜ HÏ›·˜ K·Ú‰ÈÔÏfiÁÔ˜ YÔÙ¤Ú·Ú¯Ô˜ Â.·.
¶APA°ONTE™ KIN¢YNOY - ∂¶π¢∏ªπ√§√°π∞ ∂ȉËÌÈÔÏÔÁ›· ¢˘ÛÏÈȉ·ÈÌÈÒÓ Û ∂ÏÏËÓÈÎfi ¢Â›ÁÌ·Ø Ô ƒfiÏÔ˜ ∫ÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈÎÒÓ Î·È ¢È·ÈÙËÙÈÎÒÓ ¶·Ú·ÁfiÓÙˆÓ Î·ıÒ˜ Î·È ÙÔ˘ ∆ÚfiÔ˘ ∑ˆ‹˜: Ë ªÂϤÙË ∞ÙÙÈ΋.
4
∫·Ù·ÓÔÌ‹ ÙˆÓ §Èȉ›ˆÓ ∞›Ì·ÙÔ˜ ÛÙËÓ ∂ÏÏ¿‰· M¤ÏË Õı˘ÚÔ˜ B·Û›ÏÂÈÔ˜
¡. ∆˙‹Ì·, Ã. ¶›ÙÛ·‚Ô˜, ¢. ¶·Ó·ÁȈٿÎÔ˜, Ã. ÃÚ˘ÛÔ¯fiÔ˘, π. ™Îԇ̷˜, ∂˘. ¶ÔÏ˘¯ÚÔÓfiÔ˘ÏÔ˜, ∞. ∑·Ì¤Ï·˜, Ã. ™ÙÂÊ·Ó¿‰Ë˜
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΢ °·ÓˆÙ¿Î˘ EÌÌ·ÓÔ˘‹Ï E›ÎÔ˘ÚÔ˜ K·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ I·ÙÚÈ΋˜ ™¯ÔÏ‹˜
¶A£OºY™IO§O°IA ∏ ∂ÌÊ¿ÓÈÛË ÃÚfiÓÈ·˜ ¡ÂÊÚÈ΋˜ ¡fiÛÔ˘ Û ∞ÛıÂÓ›˜ Ì π‰ÈÔ·ı‹ À¤ÚÙ·ÛË ˘fi ∞ÁˆÁ‹
9
µ·Û›ÏÂÈÔ˜ ™¿Ô˘ÁÎÔ˜, ªˆ˘Û‹˜ ∂ÏÈÛ¿Ê
¶·ÓÂÈÛÙËÌ›Ô˘ HÚ·ÎÏ›Ԣ ¶ÂÚÈÊÂÚÂÈ·Îfi ¶·ÓÂÈÛÙËÌÈ·Îfi NÔÛÔÎÔÌÂ›Ô HÚ·ÎÏ›Ԣ KÚ‹Ù˘ EÏÈÛ¿Ê Mˆ˘Û‹˜ K·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ I·ÙÚÈ΋˜ ™¯ÔÏ‹˜
K§INIKE™ ME§ETE™ ¶ÔÈfi ı· Â›Ó·È ÙÔ ∞ÓÙÈ˘ÂÚÙ·ÛÈÎfi ¶ÚÒÙ˘ ∂ÈÏÔÁ‹˜;
12
πˆ¿ÓÓ˘ °Ô˘‰¤‚ÂÓÔ˜
¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ ¶ÂÚÈÊÂÚÂÈ·Îfi ¶·ÓÂÈÛÙËÌÈ·Îfi NÔÛÔÎÔÌÂ›Ô Iˆ·ÓÓ›ÓˆÓ KÔÏÔ‚Ô‡ °ÂÓÔ‚¤Ê· K·Ú‰ÈÔÏfiÁÔ˜
∂¡¢π∞º∂ƒ√¡ ¶∂ƒπ™∆∞∆π∫√
14
∂ÈÚ‹ÓË °·˙‹, ∂˘¿ÁÁÂÏÔ˜ §˘ÌÂÚfiÔ˘ÏÔ˜, ªˆ˘Û‹˜ ∂ÏÈÛ¿Ê
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˘
£EPA¶EIA — ºAPMAKA MÈÏÈ·ÓÔ‡ EϤÓË K·Ú‰ÈÔÏfiÁÔ˜ EÈÌÂÏËÙ‹˜ A’ Ù˘ K·Ú‰ÈÔÏÔÁÈ΋˜
™˘Á¯ÔÚ‹ÁËÛË ™Ù·Ù›Ó˘ Ì ∞ÛÈÚ›ÓË Î·È ¢Â˘ÙÂÚÔÁÂÓ‹˜ ¶ÚfiÏË„Ë
16
∂ÈÚ‹ÓË °·˙‹, ªˆ˘Û‹˜ ∂ÏÈÛ¿Ê
KÏÈÓÈ΋˜ Î·È Y‡ı˘ÓÔ˜ §Èȉ·ÈÌÈÎÔ‡ I·ÙÚ›Ԣ T˙·Ó›Ԣ NÔÛÔÎÔÌ›Ԣ ¶ÂÈÚ·ÈÒ˜ ¶›ÙÛ·‚Ô˜ XÚ‹ÛÙÔ˜
ÃÔÚ‹ÁËÛË ∞ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙË ¢Â˘ÙÂÚÔÁÂÓ‹ ¶ÚfiÏË„Ë Ù˘ πÛ¯·ÈÌÈ΋˜ ∫·Ú‰È·Î‹˜ ¡fiÛÔ˘
18
ª. ∫ˆÛÙ·¿ÓÔ˜, ª. ∂ÏÈÛ¿Ê
AÓ·ÏËÚˆÙ‹˜ K·ıËÁËÙ‹˜ K·Ú‰ÈÔÏÔÁ›·˜, I·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ IÔÎÚ¿ÙÂÈÔ NÔÛÔÎÔÌÂ›Ô AıËÓÒÓ
¶POTEINOMENH BIB§IO°PAºIA
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ÙˆÓ ÏÈȘ ¤ ¯ · Ú · Ù · È ÈÓ ÛÂ Ô˘Ó ·fi ‰ Á ¯ ¤ Û ¿ ˘ Ô ˜ Â Ó ∏ ÏË π∫ Ì̇ÚÈ· ŒÏ ÂϤÙË ∞∆∆ Ô Ì Ù Ë · 1/3 ·fi Î Â Â Ô Í ∆ Ë · › Ï . Ú ¤ ‡ Ù Ù Ô · ˘ Ì Î Ô Û ˘ fi ¶ÂÚ› ÒÓ ·ÛÌ· ·˘Ù ÈÎÔ‡ ÏËı Ó Ú ¤ Ë Ï Ï Ì ∂ ˘ ÙˆÓ ·Ó‰Ú Û ˘ % Ô Ô 6 Ù Ù 3 ™ · Ô . Ì Ó ∆ Á › . ‰›ˆ ¢ÙÈÎfi ‰Â ·Û˘ ÙÔ˘ ›ˆÓ ‰ÂÓ Ù ‰ È ˆ Û Û ¿ È Ô Ù Ï Ú · Î Ó È ˆ Ù ˜ Ù ÙË ¤Ó· ·Ó È·Ù·Ú·¯¤˜ ›ÁÓˆÛË ‰ È Â ˜ ÂÌÊ¿ÓÈÛË ¤ ¯ Ù ¤ ∏ Û Ó ˆ . Â Ó ) ‰ Á ‹ Î ˜ È Â ‡ Ù Ì Â˘ Ó ·˘ÙÔ › ‹ Ê·ÚÌ·Î Ó Á˘Ó·ÈÎÒ ˆ ‹ Ù Î Ë ·ÔÙÂÏÂ È Û Ù % · Ë 7 Ù Ù 4 È Ú ¤ · È Ô Ù ‰ ˘ ( È ı‹ Á‹ η Ì ȉÈÔ· ΋ ›ÂÛË ·Ì›· ·Áˆ · Î ˜ È › Ú Â Ó Ë Ó ‡ Ù Â Ô Ú ı ı Û · ˘ · Ë Â ·ÎÔÏÔ . ÔÌ· ·˘Ù¿ ˜ ÓfiÛÔ˘ Û Ù ‹ ¿ Î È · · ›‰· Ú Ù Ú Ê Û Â Â Ù Ó È fi · Ï ˜ Î Ë · Ì È Ë Ó · ¯ ÎÙ ¯Úfi ÔÓÙ·È Û ÛÙÈÎfi ‰Â› ÏÔ‰È›Ó ˆ Ì Ò Ó È · Á  ˘ Ì Ô Ô Ú › · Ù Ó Û ‹ ‚ ÂÈ ‰˘ÛÌÂÓ ÓÈÛÙ‹˜ ·Û ÂÚfiÏË Ú¤ ˆ Ù Á Û · ·ÎÔ ·fi Ë Ù Ì Ï Ó Ú Ô · ¯ ¿ Ê Ô L È fi D Ù Î L fi È Ù ÍÂ Î·È Ë ∏ ÔÙÂÏÂÛÌ· BPLA ¤‰ÂÈ · T Ô O Ú ¤ÚÙ·Û˘.  C Ù S ˘ fi A Û ˜ Ë Û Ë È Ù Ù ¤ Ú Ï Â ·  › Â È ∏ Ì ÛÙË ıÂÚ· ∞ª∂∞ ›ӷ ·ÁÁÂÈ·È , ‰ ˜ fi › Ú Î Ú · È ˆ Î Ù ¯ Ë Ô Ú ‹ Ó ˘ ˘ ÈÔ ÓË ÌÂ È ÙÔÓ Î›Ó‰ ‹ ¯ˆÚ›˜ ‰ Â Ó Â Ò Ì È Â Ë Ù¿. ∏ ¯ÔÌ Ï Û È fi Ë Ú Ï Ó Ô ˆ › Ó ¯ Ú È Â Ù Ô Û · Î · Ì· ÙËÓ È·Ù›Ó˘ Ì οıÂ Ê¿Ú Ù È Û Ù Ë fi ˘ ÛÙÂÊ·Ó Û Ù fi Ë Á Ë ‹ · „ Ú Ë Ô Ô Ï Ú ¯ fi  Á Ú fiÙ Û˘ ·. ∆¤ÏÔ˜ ÙÂÚÔÁÂÓ‹ ˆÓ ÂÚÈÛÛ Ù ˘ Ù Â · ¿ ‰ Ì Ì Û Ë · ¤ Ù ‚ Ï Â Ì fi Ù ˘ Ô Ô ÎÒÓ Û ıÂÙÈο · ÎÒÓ Ì ÛÎ È · Ù Ú Ô Â È Ì ‚ È Û¯fiÏÈ·. ‹ È · Û Ù Ó Î È · Ú ˜ È ¯ Ë Â ¤ Û Û Ì Ë ‹ È ˆÙ Ú‹Á ¤¯ÂÈ ‰Â›Í ÈÎfi Ì ÂÚ ·˜ Ó Ù Â · ‰ Ù Û ˘ È Ô Ú Û Â fi ·˜ ÃÂÈÌÒÓ Ó › Ï Ô H Ú ¤ ·›·˜ Ó Ê · È ‰ Ó Ù·È ¤Ó·  ™‡ÓÙ·Í˘ ˜ ‹ Ù Ó ˘ ı ‰ËÌÔÛȇ ˘ ¢ÈÂ
Ù·ÍË Ó ‡ ™ ˜ Ë T
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
∂ȉËÌÈÔÏÔÁ›· ¢˘ÛÏÈȉ·ÈÌÈÒÓ Û ∂ÏÏËÓÈÎfi ¢Â›ÁÌ·Ø Ô ƒfiÏÔ˜ ∫ÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈÎÒÓ Î·È ¢È·ÈÙËÙÈÎÒÓ ¶·Ú·ÁfiÓÙˆÓ Î·ıÒ˜ Î·È ÙÔ˘ ∆ÚfiÔ˘ ∑ˆ‹˜: Ë ªÂϤÙË ∞ÙÙÈ΋ ∫·Ù·ÓÔÌ‹ ÙˆÓ §Èȉ›ˆÓ ∞›Ì·ÙÔ˜ ÛÙËÓ ∂ÏÏ¿‰· ¡. ∆˙‹Ì·1, Ã. ¶›ÙÛ·‚Ô˜2, ¢. ¶·Ó·ÁȈٿÎÔ˜1, Ã. ÃÚ˘ÛÔ¯fiÔ˘2, π. ™Îԇ̷˜2, ∂˘. ¶ÔÏ˘¯ÚÔÓfiÔ˘ÏÔ˜1, ∞. ∑·Ì¤Ï·˜1, Ã. ™ÙÂÊ·Ó¿‰Ë˜2 1. ∆Ì‹Ì· ∂ÈÛÙ‹Ì˘ ¢È·ÈÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜, ÷ÚÔÎfiÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ, ∞ı‹Ó· 2. 1Ë ¶·ÓÂÈÛÙËÌȷ΋ ∫·Ú‰ÈÔÏÔÁÈ΋ ∫ÏÈÓÈ΋, π·ÙÚÈ΋ ™¯ÔÏ‹ ∂ıÓÈÎÔ‡ Î·È ∫·Ô‰ÈÛÙÚÈ·ÎÔ‡ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ
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4
∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÔÏÏ¿ ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ ÂÈÎ‡ÚˆÛ·Ó ÙÔÓ ·ÚÓËÙÈÎfi ÚfiÏÔ Ù˘ ˘ÂÚ-/‰˘ÛÏÈȉ·ÈÌ›·˜ ÛÙËÓ ·ıËÚÔÛÎÏËÚ˘ÓÙÈ΋ ÓfiÛÔ. √È ÂȉËÌÈÔÏÔÁÈΤ˜ ·ÏÏ¿ Î·È ÔÈ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ·ÔÎ¿Ï˘„·Ó, ·Ú¯Èο, ÙË Û¯¤ÛË Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ Ì ÙÔÓ Î›Ó‰˘ÓÔ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘, ÏfiÁˆ Ù˘ ¢¯ÂÚÔ‡˜ ÌÂϤÙ˘ Ù˘ ÚÒÙ˘, Û ¤Ú¢Ó˜ ‰›Ô˘1. øÛÙfiÛÔ, ÙÒÚ· ϤÔÓ, ˘¿Ú¯ÂÈ ¤Ó·˜ ·ÍÈÔÛËÌ›ˆÙÔ˜ fiÁÎÔ˜ ÏËÚÔÊoÚÈÒÓ Û¯ÂÙÈο Ì ÙËÓ Î·Ù·ÓÔÌ‹ Î·È ÚÔÁÓˆÛÙÈ΋ ·Í›· Î·È ¿ÏÏˆÓ ÏÈȉ›ˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÏÈÔÚˆÙÂ˚ÓÒÓ ÛÙË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ1,4. ™Â ÙÔ‡ÙÔ ÙÔ ÛËÌ›Ô, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ÈÛ¯‡˜ ÙˆÓ Û¯¤ÛÂˆÓ ÌÂٷ͇ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ Î·È ·ıËÚÔÛÎÏ‹Ú˘ÓÛ˘, Â›Ó·È ‰˘Ó·Ùfi Ó· ÂËÚ·ÛÙ› ·fi ‰È¿ÊÔÚÔ˘˜ ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È ÂÓ Á¤ÓÂÈ Ì ÙÔÓ ÙÚfiÔ ˙ˆ‹˜. ∏ ÌÂϤÙË Framingham (Framingham Heart Study) ÚÒÙË ·Ó·ÎÔ›ÓˆÛ fiÙÈ Ë ‰È·Ù·Ú·Á̤ÓË ·ÓÔ¯‹ ÛÙËÓ ÁÏ˘Îfi˙Ë, Ù· ›‰· Ù˘ ·ÚÙËÚȷ΋˜ ȤÛˆ˜ Î·È ÙÔ Î¿ÓÈÛÌ· ÌÔÚÔ‡Ó Ó· ÙÚÔÔÔÈ‹ÛÔ˘Ó ÙËÓ Â›‰Ú·ÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ ÛÙÔÓ ÛÙÂÊ·ÓÈ·›Ô ΛӉ˘ÓÔ1. ∂ÈÚfiÛıÂÙ·, ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈΤ˜ ÌÂϤÙ˜5 ÚÔÙ›ÓÔ˘Ó Ì›· ·Ó¿ÛÙÚÔÊË Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ÎÔÈÓˆÓÈ΋˜ ηٿÛÙ·Û˘ Î·È ÙÔ˘ ‡„Ô˘˜ ÙˆÓ ‰È·ÊfiÚˆÓ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜. ∂›Ó·È ›Û˘ ÁÓˆÛÙfi, fiÙÈ ‰È·ÈÙËÙÈΤ˜ Ú·ÎÙÈΤ˜ Û¯ÂÙ›˙ÔÓÙ·È ÈÛ¯˘Ú¿ ÙfiÛÔ Ì ÙË Û˘¯ÓfiÙËÙ· Ù˘ ‰˘ÛÏÈȉ·ÈÌ›·˜ fiÛÔ Î·È Ì ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘1,6-7. °È· ·ÈÒÓ˜, ÔÈ ŒÏÏËÓ˜ ·ÎÔÏÔ˘ıÔ‡Û·Ó ¤Ó· ·Ú·‰ÔÛÈ·Îfi ÚfiÙ˘Ô ‰È·ÙÚÔÊ‹˜, ÙË «ªÂÛÔÁÂȷ΋ ¢È·ÙÚÔÊ‹»8,9. ¶·ÚfiÙÈ ÙÔ ‰È·ÙÚÔÊÈÎfi ·˘Ùfi ÚfiÙ˘Ô Û˘ÁΤÓÙÚˆÛ ÙÔ
ÂӉȷʤÚÔÓ ÙˆÓ ÌÂÏÂÙËÙÒÓ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·10-12, Ë Û¯¤ÛË ÙÔ˘ Ì ÙËÓ Û˘¯ÓfiÙËÙ· Î·È ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‰˘ÛÏÈȉ·ÈÌ›·˜ ‰ÂÓ ¤¯ÂÈ Ï‹Úˆ˜ ηٷÓÔËı›. ¢Â‰Ô̤Ó˘ Ù˘ ·Ô˘Û›·˜ ÚfiÛÊ·ÙˆÓ ÛÙÔȯ›ˆÓ Û¯ÂÙÈο Ì ٷ ›‰· ÏÈȉ·ÈÌ›·˜ ÛÙÔÓ ∂ÏÏËÓÈÎfi ÏËı˘ÛÌfi, ‰ÈÂÚÂ˘Ó‹Û·Ì ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÂȤ‰ˆÓ Ù˘ ÔÏÈ΋˜-, HDL-, LDL-, ÔÍÂȉˆÌ¤Ó˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘, ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ÏÈÔÚˆÙ½Ó˘ (·). ø˜ ÛÎÔfi ›¯·Ì ›Û˘, ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙˆÓ ıÂڷ¢ÙÈÎÒÓ ¯ÂÈÚÈÛÌÒÓ Ù˘ ‰˘ÛÏÈȉ·ÈÌ›·˜ Î·È ÙÔ˘ ÔÛÔÛÙÔ‡ ›ÁÓˆÛ˘ ·˘Ù‹˜ ÛÂ Ù˘¯·›Ô ‰Â›ÁÌ·, ÂχıÂÚˆÓ Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘, ÂÓËϛΈÓ. ∞ÎfiÌË, ÂÎÙÈÌ‹Û·Ì ÙËÓ Û¯¤ÛË ÌÂٷ͇ Ù˘ Ù‹ÚËÛ˘ ªÂÛÔÁÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ Î·È ÙˆÓ ÂȤ‰ˆÓ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜, ηÙfiÈÓ ÂϤÁ¯Ô˘ ‰È·ÊfiÚˆÓ ÎÔÈÓˆÓÈÎÔ‰ËÌÔÁÚ·ÊÈÎÒÓ Î·È Û¯ÂÙÈ˙fiÌÂÓˆÓ Ì ÙÔÓ ÙÚfiÔ ˙ˆ‹˜ ·Ú·ÁfiÓÙˆÓ.
ª∂£√¢√π ¶ÏËı˘ÛÌfi˜ Ù˘ ÌÂϤÙ˘ ∏ ÌÂϤÙË ‰ÈÂÍ‹¯ıË ÛÙÔ ÓÔÌfi ∞ÙÙÈ΋˜ (78% Û ·ÛÙÈΤ˜ Î·È 22% Û ·ÁÚÔÙÈΤ˜ ÂÚÈÔ¯¤˜). ∆Ô ‰Â›ÁÌ· ‹Ù·Ó Ù˘¯·›Ô Ì ÔÏ˘ÛÙ·‰È·Î‹ ‰È·ÛÙڈ̿وÛË Ô˘ ‚·Û›ÛÙËΠÛÙËÓ Î·Ù·ÓÔÌ‹ ËÏÈΛ·˜ - ʇÏÔ˘ ÙÔ˘ ¡ÔÌÔ‡ ∞ÙÙÈ΋˜, Û‡Ìʈӷ Ì ÛÙÔȯ›· Ù˘ ∂ıÓÈ΋˜ ™Ù·ÙÈÛÙÈ΋˜ ÀËÚÂÛ›·˜ (·ÔÁÚ·Ê‹ ÙÔ˘ 2001). ∞fi ÙÔÓ ª¿ÈÔ ÙÔ˘ 2001 ̤¯ÚÈ ÙÔÓ ∞‡ÁÔ˘ÛÙÔ 2002, 3.355 οÙÔÈÎÔÈ ÂÈϤ¯ÙËÎ·Ó Ì ÙÚfiÔ Ù˘¯·›Ô ÁÈ· Ó· Û˘ÌÌÂÙ¿Û¯Ô˘Ó ÛÙË ÌÂϤÙË. ∞fi ·˘ÙÔ‡˜, 2.282 fiÓÙˆ˜ Û˘ÌÊÒÓËÛ·Ó Ó· Ï¿‚Ô˘Ó Ì¤ÚÔ˜ (ÔÛÔÛÙfi Û˘ÌÌÂÙÔ¯‹˜ 68%). ∂Î·È‰Â˘Ì¤ÓÔ ÚÔÛˆÈÎfi (ηډÈÔÏfiÁÔÈ, ‰È·ÈÙÔÏfiÁÔÈ, ÓÔÛËÏÂ˘Ù¤˜) ¤Ï·‚Â Û˘ÓÂÓÙ‡ÍÂȘ Ì ÙË ¯Ú‹ÛË Ù˘ÔÔÈË̤-
ÓÔ˘ ÂÚˆÙËÌ·ÙÔÏÔÁ›Ô˘, ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÌÌÂÙ¤¯ÔÓÙ˜. √ ·ÚÈıÌfi˜ ÙˆÓ ·ÙfiÌˆÓ Â›Ó·È ÈηÓfi˜ Ó· ÂÎÙÈÌ‹ÛÂÈ ‰È·ÊÔÚ¤˜ ·Ó¿ÌÂÛ· ÛÙȘ ‰ÈÂÚ¢ÓÔ‡ÌÂÓ˜ ·Ú·Ì¤ÙÚÔ˘˜, ÌÂÁ·Ï‡ÙÂÚ˜ ÙÔ˘ 20%, ÂÈÙ˘Á¯¿ÓÔÓÙ·˜ ÛÙ·ÙÈÛÙÈ΋ ÈÛ¯‡ >0,80 Î·È Â›Â‰Ô Èı·ÓfiÙËÙ·˜ < 0,05 (ÙÈÌ‹ P).
¢È·ÙÚÔÊÈ΋ ·ÍÈÔÏfiÁËÛË ∏ ̤ÛË Î·Ù·Ó¿ÏˆÛË ÙˆÓ ‰È·ÊfiÚˆÓ ÙÚÔÊ›ÌˆÓ ˘ÔÏÔÁ›ÛÙËΠ̠‚¿ÛË ¤Ó· ¤Á΢ÚÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Û˘¯ÓfiÙËÙ·˜ ηٷӿψÛ˘ ÙÚÔÊ›ÌˆÓ (FFQ). °È· ÙËÓ Î·Ù·Ó¿ÏˆÛË ÙÚÔÊ›ÌˆÓ Ô˘ ÚÔÛÂÁÁ›˙Ô˘Ó ÙÔ ªÂÛÔÁÂÈ·Îfi ‰È·ÙÚÔÊÈÎfi ÚfiÙ˘Ô, ‚·ıÌÔÏÔÁ‹Û·Ì Ì 0 ÙËÓ Û¿ÓÈ· ‹ η̛· ηٷӿψÛË ÙÔ˘˜, Ì 1 ÙËÓ Î·Ù·Ó¿ÏˆÛË ·fi 1 ¤ˆ˜ 4 ÊÔÚ¤˜ ÌËÓÈ·›ˆ˜, Ì 2 ÙȘ 5 ¤ˆ˜ 8 ÊÔÚ¤˜ ÌËÓÈ·›ˆ˜, Ì 3 ÙȘ 9 ¤ˆ˜ 12 ÊÔÚ¤˜ ·Ó¿ Ì‹Ó·, Ì 4 ÙȘ 13 ¤ˆ˜ 18 ÊÔÚ¤˜ ·Ó¿ Ì‹Ó· Î·È Ì 5 ÙË Û¯Â‰fiÓ Î·ıËÌÂÚÈÓ‹ ηٷӿψÛË Î¿ı ̛·˜ ·fi ÙȘ 11 ‚·ÛÈΤ˜ ÔÌ¿‰Â˜ ÙÚÔÊ›ÌˆÓ Ù˘ ÎÏ·ÛÛÈ΋˜ ˘Ú·Ì›‰·˜ ªÂÛÔÁÂȷ΋˜ ‰È·ÙÚÔÊ‹˜. ŒÙÛÈ ÚԤ΢„ ̛· ‚·ıÌÔÏÔÁ›· ·fi 0 ¤ˆ˜ 55. À„ËϤ˜ ÙÈ̤˜ ÛÙÔÓ ÚÔÙÂÈÓfiÌÂÓÔ ›Ó·Î· ‚·ıÌÔÏÔÁ›·˜ ‰ÂÈÎÓ‡Ô˘Ó ˘ÈÔı¤ÙËÛË Ù˘ ·Ú·‰ÔÛȷ΋˜ ªÂÛÔÁÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ (Ë ÔÔ›·, ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ̤ÙÚÈ· ηٷӿψÛË Ï›Ô˘˜ Î·È ˘„ËÏfi ÏfiÁÔ ÌÔÓÔ·ÎfiÚÂÛÙˆÓ ÚÔ˜ ÎÔÚÂṲ̂ӷ Ï›Ë), ÂÓÒ ¯·ÌËÏfiÙÂÚ˜ ÙÈ̤˜ Â›Ó·È ÂÓ‰ÂÈÎÙÈΤ˜ ÌÈ·˜ «¢˘ÙÈÎÔ‡ Ù‡Ô˘» ‰È·ÙÚÔÊ‹˜.
¢ËÌÔÁÚ·ÊÈο, ÎÏÈÓÈο Î·È Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙÔÓ ÙÚfiÔ ˙ˆ‹˜ ¯·Ú·ÎÙËÚÈÛÙÈο ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, ÂÚÈÂÏ¿Ì‚·Ó ‰ËÌÔÁÚ·ÊÈο ¯·-
¶∞ƒ∞°√¡∆∂™ ∫π¡¢À¡√À – E¶π¢∏ªπ√§√°π∞ Ú·ÎÙËÚÈÛÙÈο fiˆ˜, ʇÏÔ, ËÏÈΛ·, ÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË (̤ÛÔ ÂÙ‹ÛÈÔ ÂÈÛfi‰ËÌ· ηٿ ÙËÓ ÙÂÏÂ˘Ù·›· ÙÚÈÂÙ›·), ÙÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô Î·È ÙÔ Î¿ÓÈÛÌ·. ∏ Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÚÔÛ‰ÈÔÚ›ÛÙËΠˆ˜ ¯ÚfiÓÔ˜ ·ÊÈÂڈ̤ÓÔ˜ Û ‰Ú·ÛÙËÚÈfiÙËÙ· ÔÚÈṲ̂Ó˘ ¤ÓÙ·Û˘ Î·È ‰È¿ÚÎÂÈ·˜. √ ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ˘ÔÏÔÁ›ÛÙËΠˆ˜ ‚¿ÚÔ˜ (Û ¯ÈÏÈfiÁÚ·ÌÌ·) ‰È· ‡„Ô˜ (Û ̤ÙÚ·)2. ø˜ ·¯˘Û·ÚΛ· ÔÚ›ÛÙËΠ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙÔ˘ > 29,9 Kg/m2. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ÌÂÙÚ‹ıËΠÙÚÂȘ ÊÔÚ¤˜ ÛÙÔ ‰ÂÍÈfi ¿Óˆ ¿ÎÚÔ. √È ·ÛıÂÓ›˜ Ì ̤۷ ›‰· ·ÚÙËÚȷ΋˜ ȤÛˆ˜ ›Û· ‹ ÌÂÁ·Ï‡ÙÂÚ· Ì 140/90 mm Hg ηıÒ˜ Î·È ÂΛÓÔÈ ˘fi ·ÓÙÈ˘ÂÚÙ·ÛÈ΋ ·ÁˆÁ‹ ηٷٿ¯ıËÎ·Ó ÛÙÔ˘˜ ˘ÂÚÙ·ÛÈÎÔ‡˜. ø˜ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›· ÔÚ›ÛÙËÎ·Ó Â›Â‰· ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ÔÚÔ‡ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 220 mg/dl ‹ Ë ¯Ú‹ÛË ˘ÔÏÈȉ·ÈÌÈÎÒÓ ·Ú·ÁfiÓÙˆÓ ÂÓÒ ˆ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘, Ë ÁÏ˘Îfi˙Ë ·›Ì·ÙÔ˜ ÓËÛÙ›·˜ > 125 mg/dl ηıÒ˜ Î·È Ë ¯Ú‹ÛË ·ÓÙȉȷ‚ËÙÈ΋˜ (‰È·ÈÙËÙÈ΋˜ ‹ Ê·Ú̷΢ÙÈ΋˜) ·ÁˆÁ‹˜. ¶ÂÚ·ÈÙ¤Úˆ ÏÂÙÔ̤ÚÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÙÔ˘˜ ÛÎÔÔ‡˜ Î·È ÙÔÓ Û¯Â‰È·ÛÌfi Ù˘ ÌÂϤÙ˘ ∞∆∆π∫∏, ¤¯Ô˘Ó ‹‰Ë ·ÚÔ˘ÛÈ·ÛÙ› ·ÏÏÔ‡11,15.
™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ŸÏ˜ ÔÈ ·Ó·ÊÂÚfiÌÂÓ˜ ÙÈ̤˜ P ‚·Û›ÛÙËÎ·Ó Û ‰ÔÎÈ̷ۛ˜ ‰ÈÏ‹˜ ηÙ‡ı˘ÓÛ˘ Î·È Û˘ÁÎÚ›ıËÎ·Ó ÌÂ Â›Â‰Ô ÛËÌ·ÓÙÈÎfiÙËÙ·˜ 5%. °È· fiÏÔ˘˜ ÙÔ˘˜ ÛÙ·ÙÈÛÙÈÎÔ‡˜ ˘ÔÏÔÁÈÛÌÔ‡˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ ÛÙ·ÙÈÛÙÈÎfi ·Î¤ÙÔ SPSS 11.0 software (SPSS Inc. 2002, Illinois, USA).
∞¶√∆∂§∂™ª∞∆∞ ¢ËÌÔÁÚ·ÊÈο, ÎÏÈÓÈο Î·È Û˘ÌÂÚÈÊÔÚÈÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1.
∫·Ù·ÓÔÌ‹ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ √È Ì¤Û˜ ÙÈ̤˜ ÙˆÓ ‰ÈÂÚ¢ÓÔ‡ÌÂÓˆÓ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ ηıÒ˜ Î·È Ù· ÔÛÔÛÙ¿ ·ıÔÏÔÁÈÎÒÓ ÂȤ‰ˆÓ ÙÔ˘˜ Û ¿Ó‰Ú˜ Î·È Á˘Ó·›Î˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ™˘ÌÏËڈ̷ÙÈο Û ·˘Ù¤˜ ÙȘ ÏËÚÔÊÔڛ˜, ÙÔ 5% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 13% ÙˆÓ Á˘Ó·ÈÎÒÓ Â›¯·Ó ›‰· ¯ÔÏËÛÙÂÚfiÏ˘ ¿Óˆ ·fi 240 mg/dl. Ÿˆ˜ ‹Ù·Ó ·Ó·ÌÂÓfi-
¶›Ó·Î·˜ 1: ÷ڷÎÙËÚÈÛÙÈο Û˘ÌÌÂÙ¯fiÓÙˆÓ ÛÙË ÌÂϤÙË (% ηٿ ʇÏÔ)
∏ÏÈΛ· (¤ÙË) ªÔÚʈÙÈÎfi Â›Â‰Ô ñ ¯·ÌËÏfi ñ ̤ÛÔ ñ ˘„ËÏfi ∫¿ÓÈÛÌ· ñ √˘‰¤ÔÙ ηÓÈÛÙ‹˜ ñ ∫·ÓÈÛÙ‹˜ ñ ¶ÚÒËÓ Î·ÓÈÛÙ‹˜ ∂›Â‰Ô Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ñ ∫·ıÈÛÙÈ΋ ˙ˆ‹ ñ ◊È· ‹ ̤ÙÚÈ· ñ ŒÓÙÔÓË ∞ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘ ¶·¯˘Û·ÚΛ· ¢È·ÙÚÔÊÈ΋ ‚·ıÌÔÏÔÁ›· (∂‡ÚÔ˜: 0 – 55) ∫·Ù·Ó¿ÏˆÛË ·ÏÎÔfiÏ (ml/d)
ÕÓ‰Ú˜ (1.128 ‹ 49%)
°˘Ó·›Î˜ (1.154 ‹ 51%)
P
47 ± 18
47 ± 13
245 (22%) 429 (38%) 454 (40%)
290 (25%) 440 (38%) 424 (37%)
357 (32%) 544 (48%) 227 (20%)
638 (55%) 441 (38%) 75 (7%)
664 (59%) 234 (21%) 230 (20%) 431 (38%) 107 (10%) 272 (25%)
722 (63%) 177 (15%) 255 (22%) 276 (24%) 82 (7%) 194 (17%)
< 0,001 0,039 < 0,001
35 ± 12 220 ± 55
37 ± 12 90 ± 40
< 0,001 < 0,001
0,197 0,098
< 0,001
0,003
ÌÂÓÔ, fiÙ·Ó ÂÛÙÈ¿Û·Ì ÙËÓ ·Ó¿Ï˘Û‹ Ì·˜ Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (>50 ÂÙÒÓ) ·Ú·ÙËÚ‹Û·Ì fiÙÈ ÙÔ 48% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 55% ÙˆÓ Á˘Ó·ÈÎÒÓ Â›¯·Ó ›‰· ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ >200 mg/dl (Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2). ¶·ÚfiÌÔÈ· Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ‹Ù·Ó Î·È Ù˘ HDL – ¯ÔÏËÛÙÂÚfiÏ˘ (¶›Ó·Î·˜ 2). ¶·Ú·ÙËÚ‹Û·ÌÂ, ·ÎfiÌË, fiÙÈ ÙÔ 21% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 7% ÙˆÓ Á˘Ó·ÈÎÒÓ Â›¯·Ó Ôχ ¯·ÌËÏ‹ HDL – ¯ÔÏËÛÙÂÚfiÏË (<35 mg/dl). ª›· ÔÌ¿‰· Ì ȉȷ›ÙÂÚÔ ÂӉȷʤÚÔÓ Â›Ó·È ·˘Ù‹ ÙˆÓ ·ÙfiÌˆÓ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË ·ÏÏ¿ ¯·ÌËÏ‹ HDL ¯ÔÏËÛÙÂÚfiÏË. ™ÙÔÓ ÏËı˘ÛÌfi Ì·˜, 19% ÙˆÓ ·Ó‰ÚÒÓ Î·È 12% ÙˆÓ Á˘Ó·ÈÎÒÓ Ô˘ ›¯·Ó Ê˘ÛÈÔÏÔÁÈο ›‰· ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ (ÁÈ· ÙËÓ ·ÎÚ›‚ÂÈ· < 200 mg/dl) ›¯·Ó ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘ ÌÈÎÚfiÙÂÚ· ÙˆÓ 35 Î·È 45 mg/dl, ·ÓÙ›ÛÙÔȯ·. ∆¤ÏÔ˜, ÙÔ 52% ÙˆÓ ·Ó‰ÚÒÓ Î·È 48% ÙˆÓ Á˘Ó·ÈÎÒÓ Â›¯·Ó ›‰· LDL ¯ÔÏËÛÙÂÚfiÏ˘ ÌÂÁ·Ï‡ÙÂÚ· ·fi 130 mg/dl (Ù· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2). ∂›Ó·È ÁÓˆÛÙfi ˆ˜ Ë ËÏÈΛ· Â›Ó·È ¤Ó·˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ Û¯ÂÙ›˙ÂÙ·È Î·ÏÒ˜ Ì ٷ ›‰· ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜. ™ÙË ÌÂϤÙË Ì·˜, Ë ËÏÈΛ· Û¯ÂÙ›ÛÙËΠıÂÙÈο Û ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ‚·ıÌfi Ì ÙȘ ÌÂÙÚ‹ÛÂȘ fiÏˆÓ ÙˆÓ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜, ÙfiÛÔ ÛÙÔ˘˜ ¿Ó‰Ú˜ fiÛÔ Î·È ÛÙȘ Á˘Ó·›Î˜, Ì ÂÍ·›ÚÂÛË ÙȘ ÌÂÙÚ‹ÛÂȘ ÙˆÓ ÂȤ‰ˆÓ Ù˘ HDL¯ÔÏËÛÙÂÚfiÏ˘ (∂ÈÎfiÓ· 1). ŒÙÛÈ,
ÏÔÈfiÓ, ÂÂÎÙ›ӷÌ ٷ Â˘Ú‹Ì·Ù¿ Ì·˜ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·˜ ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ‰ÈÂÚ¢ÓÔ‡ÌÂÓˆÓ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜, ÌÂÙ¿ ·fi ÚÔÛ·ÚÌÔÁ‹ ÁÈ· ÙËÓ ËÏÈΛ· Î·È ·ÊÔ‡ ÂϤÁÍ·Ì ÁÈ· ¿ÏÏÔ˘˜ ÂӉ¯fiÌÂÓÔ˘˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ËÏÈΛ·, fiˆ˜ ÙÔ Ê‡ÏÔ, ÙÔ Î¿ÓÈÛÌ·, ÙÔ Â›Â‰Ô Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ÙË ‚·ıÌÔÏÔÁ›·, ÙË Û¯ÂÙÈ΋ Ì ÙËÓ Ù‹ÚËÛË Ù˘ ªÂÛÔÁÂȷ΋˜ ‰È·ÙÚÔÊ‹˜). (∆· ·ÔÙÂϤÛÌ·Ù· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û ¶›Ó·Î˜ ‹ ∂ÈÎfiÓ˜). ¶·Ú·ÙËÚ‹Û·Ì ˆ˜ Ë ÚfiÛıÂÛË Ì›·˜ ‰ÂηÂÙ›·˜ ÛÙËÓ ËÏÈΛ·, Û¯ÂÙÈ˙fiÙ·Ó Ì ›‰· ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ˘„ËÏfiÙÂÚ· ηٿ 9 mg/dl (95% ‰È·ÛÙ‹Ì·Ù· ÂÌÈÛÙÔÛ‡Ó˘ (CI) 8 11 mg/dl, p < 0,001), Ì ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ˘„ËÏfiÙÂÚ· ηٿ 13 mg/dl (95% CI: 11-16 mg/dl, p < 0,001), Ì ›‰· LDL ¯ÔÏËÛÙÂÚfiÏ˘ ˘„ËÏfiÙÂÚ· ηٿ 7 mg/ dl (95% CI:5 - 9 mg/dl, p < 0,001), Ì ›‰· ÏÈÔÚˆÙ½Ó˘ (·) ˘„ËÏfiÙÂÚ· ηٿ 1,2 mg/dl (95% CI: 0,2-1,9 mg/dl, p < 0,001), ÂÓÒ Ì ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘ ¯·ÌËÏfiÙÂÚ· ÌfiÓÔ Î·Ù¿ 0,02 (95% CI: -0,1 - 0,2 mg/dl, p = 0,352, ÂÔ̤ӈ˜, ·ÔÙ¤ÏÂÛÌ· ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi). ∂ÊfiÛÔÓ ·ÚÎÂÙÔ› ÂÚ¢ÓËÙ¤˜ ÈÛ¯˘Ú›˙ÔÓÙ·È fiÙÈ Ë ÎÔÈÓˆÓÈ΋ ηٿÛÙ·ÛË Âȉڿ ÛÙ· ›‰· ÏÈȉ·ÈÌ›·˜, ·ÍÈÔÏÔÁ‹Û·Ì ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÏÈȉ›ˆÓ Û ۯ¤ÛË Ì ÙÔ ÌÔÚʈÙÈÎfi ›‰Ô, ˆ˜ ÂÎÙÈÌËÙ‹ ÙÔ˘ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡ ÂȤ‰Ô˘ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ. ¢È·ÈÛÙÒÛ·Ì fiÙÈ Ë ÌfiÓË Û˘Û¯¤ÙÈÛË
5
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
¶›Ó·Î·˜ 2: ∫·Ù·ÓÔÌ‹ ÙÈÌÒÓ ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ Û ¿Ó‰Ú˜ Î·È Á˘Ó·›Î˜ ¯ˆÚ›˜ ÎÏÈÓÈΤ˜ ÂӉ›ÍÂȘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ ÕÓ‰Ú˜ (1.128 ‹ 49%)
°˘Ó·›Î˜ (1.154 ‹ 51%)
∂ηÙÔÛÙËÌfiÚÈ·
P*
∂ηÙÔÛÙËÌfiÚÈ·
̤ÛË ± SD
5%
95%
̤Û˱ SD
5%
95%
√ÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË (TC) (mg/dl) % ·ÙfiÌˆÓ Ì ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË > 200 mg/dl
199 ± 42 46%
137
270
195 ± 40 40%
135
266
0,033
∆ÚÈÁÏ˘ÎÂÚ›‰È· (∆g) (mg/dl) % ·ÙfiÌˆÓ Ì ÙÚÈÁÏ˘ÎÂÚ›‰È· > 150 mg/dl
138 ± 57 28%
54
313
103 ± 56 13%
44
207
< 0,001
HDL - ¯ÔÏËÛÙÂÚfiÏË (mg/dl) % ·Ó‰ÚÒÓ/Á˘Ó·ÈÎÒÓ Ì HDL < 40/50 mg/dl
44 ± 15 38%
29
66
53 ± 14 37%
33
75
< 0,001
Non - HDL - ¯ÔÏËÛÙÂÚfiÏË (mg/dl) % ·Ó‰ÚÒÓ/Á˘Ó·ÈÎÒÓ Ì non-HDL > 190 mg/dl
156 ± 44 17%
67
237
142 ± 41 11%
60
240
< 0,001
LDL - ¯ÔÏËÛÙÂÚfiÏË (mg/dl) % ·Ó‰ÚÒÓ/Á˘Ó·ÈÎÒÓ Ì LDL > 160 mg/dl
128 ± 38 15%
69
189
122 ± 36 12%
70
184
0,003
√ÍÂȉˆÌ¤ÓË LDL - ¯ÔÏËÛÙÂÚfiÏË (mg/dl) §ÈÔÚˆÙ½ÓË (·)Lp(a) (mg/dl) % ·ÙfiÌˆÓ Ì Lp(a) > 30 mg/dl
68 ± 33 18 ± 16 17%
25 2
128 57
59 ± 28 20 ± 19 16%
27 2
118 70
0,002 0,012
∏ ÙÈÌ‹ P ÚԤ΢„ ·fi ÙËÓ Û‡ÁÎÚÈÛË ·Ó‰ÚÒÓ- Á˘Ó·ÈÎÒÓ, ·ÊÔ‡ ÂÏ‹ÊıË ˘fi„Ë Ë Â›‰Ú·ÛË Ù˘ ËÏÈΛ·˜, ÙÔ˘ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜, Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È ÙÔ˘ ηӛÛÌ·ÙÔ˜.
Ô˘ ·Ú¤ÌÂÓ ıÂÙÈ΋ Î·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋, ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ‰È¿ÊÔÚÔ˘˜ ‰˘ÓËÙÈÎÔ‡˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ fiˆ˜ Ë ËÏÈΛ·, ÙÔ Ê‡ÏÔ, Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜, Ù· ›‰· Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ÔÈ Î·ÓÈÛÙÈΤ˜ Î·È ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ, ‹Ù·Ó ·˘Ù‹ ÙˆÓ ÂȤ‰ˆÓ HDL ¯ÔÏËÛÙÂÚfiÏ˘ Ì ÙÔ ÌÔÚʈÙÈÎfi ›‰Ô. (T· ÛÙÔȯ›· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û ¶›Ó·Î˜). ™˘ÁÎÂÎÚÈ̤ӷ, Ë ÔÌ¿‰· Ì ÙÔ ˘„ËÏfiÙÂÚÔ ÌÔÚʈÙÈÎfi Â›Â‰Ô Â›¯Â ηٿ ̤ÛÔ fiÚÔ ÙÈ̤˜ HDL ¯ÔÏËÛÙÂÚfiÏË ˘„ËÏfiÙÂÚ˜, Û˘ÁÎÚÈÓfiÌÂÓË Ì ÙËÓ ÔÌ¿‰· ÙˆÓ ·ÙfiÌˆÓ ¯·ÌËÏÔ‡ ÌÔÚʈÙÈÎÔ‡ ÂȤ‰Ô˘, ηٿ 2 mg/dl (95% CI: 0,7 - 3,3 mg/dl, p = 0,04). ¢ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ Û¯¤ÛÂȘ ·Ó¿ÌÂÛ· ÛÙ· ÏÈ›‰È· ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÙÔ ÂÈÛfi‰ËÌ· ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ. ∆¤ÏÔ˜, ›¯·Ì ˆ˜ ÛÎÔfi Î·È ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ηٷÓÔÌ‹˜ ÙˆÓ ÙÈÌÒÓ ÙˆÓ ÏÈȉ›ˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Û ۯ¤ÛË Ì ÙÔ Â›Â‰Ô Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Î·È Ì ÙÔ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ. øÛÙfiÛÔ, Ì ÂÍ·›ÚÂÛË Ù· ›‰· Ù˘ HDL ÛÙȘ Á˘Ó·›Î˜ - fiÔ˘ ÔÈ Ê˘ÛÈÎÒ˜ ‰Ú·ÛÙ‹ÚȘ ›¯·Ó ηٿ ̤ÛÔ fiÚÔ ÙÈ̤˜ ˘„ËÏfiÙÂÚ˜ ηٿ 4 mg/dl Û ۯ¤ÛË Ì ·˘Ù¤˜ Ô˘ ‰È‹Á·Ó ηıÈÛÙÈ΋ ˙ˆ‹ (p = 0,024), η̛· ¿ÏÏË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ‰ÂÓ ‰È·ÈÛÙÒıËΠ·Ó¿ÌÂÛ· ÛÙ· ÏÈ›‰È· ÙÔ˘ ·›Ì·ÙÔ˜ Î·È ÛÙË Ê˘ÛÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ËÏÈΛ· Î·È ÙÔÓ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ. ∂ÈϤÔÓ, Û˘ÁÎÚÈÓfiÌÂÓÔÈ
6
Ì ÙÔ˘˜ Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ Î·È ÙÔ˘˜ ˘¤Ú‚·ÚÔ˘˜, ÔÈ ·¯‡Û·ÚÎÔÈ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ ›¯·Ó ηٿ ̤ÛÔ fiÚÔ ˘„ËÏfiÙÂÚ· ÙÚÈÁÏ˘ÎÂÚ›‰È· ηٿ 25 mg/dl (p < 0,001) Î·È ¯·ÌËÏfiÙÂÚ· ›‰· HDL ηٿ 4 mg/dl (p < 0,001), ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ÙËÓ ËÏÈΛ·, ÙÔ Ê‡ÏÔ, ÙÔ Â›Â‰Ô Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, ÙȘ ‰È·ÈÙËÙÈΤ˜ Î·È ÙȘ ηÓÈÛÙÈΤ˜ Û˘Ó‹ıÂȘ. ŸÛÔÓ ·ÊÔÚ¿ Ù· ›‰· ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ Û ۯ¤ÛË Ì ÙÔÓ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜, η̛· ÛËÌ·ÓÙÈ΋ Û¯¤ÛË ‰ÂÓ ÛËÌÂÈÒıËÎÂ, ÌÂÙ¿ ·fi ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÚÔ·Ó·ÊÂÚfiÌÂÓˆÓ Û˘Á¯˘ÛÙÒÓ.
£Âڷ¢ÙÈÎÔ› ¯ÂÈÚÈÛÌÔ› Ù˘ ‰˘ÛÏÈȉ·ÈÌ›·˜ ∞fi ÂΛÓÔ˘˜ Ì ÁÓˆÛÙ¤˜ ‰È·Ù·Ú·¯¤˜ ÏÈȉ›ˆÓ (‰ËÏ·‰‹, 240 ¿Ó‰Ú˜ Î·È 280 Á˘Ó·›Î˜), ÙÔ 36% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 33% ÙˆÓ Á˘Ó·ÈÎÒÓ ·ÎÔÏÔ˘ıÔ‡Û·Ó ÌfiÓÔ ‰È·ÈÙËÙÈ΋ ·ÁˆÁ‹ ÂÓÒ ÙÔ 31% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 20% ÙˆÓ Á˘Ó·ÈÎÒÓ ‚Ú›ÛÎÔÓÙ·Ó ˘fi Û˘ÌÏËڈ̷ÙÈ΋ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹. ŒÙÛÈ, ÏÔÈfiÓ, 33% ÙˆÓ ·Ó‰ÚÒÓ Î·È 47% ÙˆÓ Á˘Ó·ÈÎÒÓ Ì ÁÓˆÛÙ¤˜ ‰È·Ù·Ú·¯¤˜ ÏÈȉ›ˆÓ ‰ÂÓ ÂÏ¿Ì‚·Ó Ԣ‰ÂÌ›· ·ÁˆÁ‹ (‰È·ÈÙËÙÈ΋ ‹ Ê·Ú̷΢ÙÈ΋). ÕÏψÛÙÂ, ·fi ÂΛÓÔ˘˜ Ô˘ ‚Ú¤ıËΠӷ ¤¯Ô˘Ó ·ıÔÏÔÁÈο ›‰· ÔÏÈ΋˜ ‹ LDL ¯ÔÏËÛÙÂÚfiÏ˘, ηٿ ÙËÓ Û˘Ó¤ÓÙ¢ÍË, ÙÔ 40% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 30% ÙˆÓ Á˘Ó·ÈÎÒÓ ·Ó¤ÊÂÚ·Ó ˆ˜ ‰ÂÓ Â›¯·Ó ›ÁÓˆÛË ·˘Ù‹˜ ÙÔ˘˜ Ù˘ ηٿÛÙ·Û˘ Î·È ˆ˜ ÔÙ¤ ÚÔËÁÔ˘Ì¤Óˆ˜ ‰ÂÓ Â›¯·Ó ÌÂÙÚ‹ÛÂÈ Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÛÙÔ ·›Ì·
ÙÔ˘˜. ∂ÈϤÔÓ, Ù· ¿ÙÔÌ· Ô˘ ÁÓÒÚÈ˙·Ó fiÙÈ Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÛÙÔ ·›Ì· ÙÔ˘˜ ‹Ù·Ó ·ıÔÏÔÁÈο, ˆÛÙfiÛÔ ‰ÂÓ ÂÏ¿Ì‚·Ó·Ó ÁÈ’ ·˘Ùfi Ô˘‰ÂÌ›· ·ÁˆÁ‹, ‹Ù·Ó ¯·ÌËÏfiÙÂÚÔ˘ ÌÔÚʈÙÈÎÔ‡ ›‰Ԣ Û ۇÁÎÚÈÛË Ì ·˘ÙÔ‡˜ Ô˘ ‚Ú›ÛÎÔÓÙ·Ó ˘fi ‰È·ÈÙËÙÈ΋ ‹ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ (10 ± 4 ¤Ó·ÓÙÈ 12 ± 4 ÂÙÒÓ Âη›‰Â˘Û˘, p < 0,001). √È ÛÙ·Ù›Ó˜ ‹Ù·Ó ÔÈ Î‡ÚÈÔÈ ˘ÔÏÈȉ·ÈÌÈÎÔ› ·Ú¿ÁÔÓÙ˜ (55% ÂÏ¿Ì‚·Ó ·ÙÔÚ‚·ÛÙ·Ù›ÓË, 15% Ú·‚·ÛÙ·Ù›ÓË, 12% ÛÈÌ‚·ÛÙ·Ù›ÓË Î·È 10% οÔÈÔ ¿ÏÏÔ Â›‰Ô˜ ÛÙ·Ù›Ó˘), ·ÎÔÏÔ˘ıÔ‡ÌÂÓ˜ ·fi ÙȘ ÊÈÌÚ¿Ù˜ (7%) Î·È ¿ÏÏ· ˘ÔÏÈȉ·ÈÌÈο Ê¿Ú̷η (≈1%). ∂ÓÙÔ‡ÙÔȘ, ÌfiÓÔ ÙÔ 49% ÙˆÓ ·Ó‰ÚÒÓ Î·È ÙÔ 51% ÙˆÓ Á˘Ó·ÈÎÒÓ ˘fi Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹, ›¯·Ó Ù· ÂÈı˘ÌËÙ¿ ›‰· ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ (< 200 mg/dl), ηٿ ÙË Û˘Ó¤ÓÙ¢ÍË.
§È›‰È· ·›Ì·ÙÔ˜ Î·È ‰È·ÈÙËÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ŒÓ·˜ ‰Â˘ÙÂÚ‡ˆÓ ÛÙfi¯Ô˜ ·˘Ù‹˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ó· ·ÍÈÔÏÔÁ‹ÛÂÈ Ù· ›‰· ÏÈȉ·ÈÌ›·˜ Û ۯ¤ÛË Ì ‰È·ÙÚÔÊÈΤ˜ Û˘Ó‹ıÂȘ. ∫·Ù’ ·Ú¯‹Ó, ÂÎÙÈÌ‹Û·Ì ÙËÓ Â›‰Ú·ÛË Ù˘ ªÂÛÔÁÂȷ΋˜ ‰›·ÈÙ·˜ ÛÙ· ‰ÈÂÚ¢ÓÔ‡ÌÂÓ· ÏÈ›‰È· (¶›Ó·Î·˜ 3). ¶·Ú·ÙËÚ‹Û·Ì ˆ˜ –ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ·ÚÎÂÙÔ‡˜ ‰˘ÓËÙÈÎÔ‡˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (Ô˘ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3) – ÔÈ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ Ô˘ ÙËÚÔ‡Û·Ó ÙË ªÂÛÔÁÂȷ΋ ‰È·ÙÚÔÊ‹ ›¯·Ó ·ÚfiÌÔÈÔ ÏÈȉ·ÈÌÈÎfi ÚÔÊ›Ï Ì ·˘ÙÔ‡˜ Ô˘ ‚Ú›ÛÎÔÓÙ·Ó «ÂÁÁ‡ÙÂ-
¶∞ƒ∞°√¡∆∂™ ∫π¡¢À¡√À – E¶π¢∏ªπ√§√°π∞ ∂ÈÎfiÓ· 1. ∂ÈÏÂÁ̤ӷ ›‰Ë ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ Î·È ËÏÈΛ· Û˘ÌÌÂÙ¯fiÓÙˆÓ (ÔÈ ÁÚ·Ì̤˜ ·ÚÈÛÙÔ‡Ó ÙË ÁÚ·ÌÌ‹ ·ÏÈÓ‰ÚfiÌËÛ˘ Î·È Ù· 95% ‰È·ÛÙ‹Ì·Ù· ÂÌÈÛÙÔÛ‡Ó˘). 100 r=0,002, p=0,3
HDL-¯ÔÏËÛÙÂÚfiÏË (mg/dl)
√ÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË (mg/dl)
500 400 300 200 100
90 80 70 60 50 40 30 20 10
0 0
20
40
60
80
0
100
0
20
40
80
100
100
400
90
r=0,2, p<0,001
350
r=0,1, p<0,001
80
300
70
Lp(a) (mg/dl)
LDL-¯ÔÏËÛÙÂÚfiÏË (mg/dl)
60
∏ÏÈΛ·
∏ÏÈΛ·
250 200 50 100
60 50 40 30 20
50
10
0
0 0
20
40
60
80
0
100
Ú·» ÛÙËÓ «¢˘ÙÈÎÔ‡ Ù‡Ô˘» ‰›·ÈÙ·. ªfiÓÔ ÔÈ ·Ú·ÙËÚÔ‡ÌÂÓ˜ ‰È·ÊÔÚ¤˜ ÛÙ· ›‰· Ù˘ ÔÍÂȉˆÌ¤Ó˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ ¤ÊÙ·Û·Ó Û ÛÙ·ÙÈÛÙÈ΋ ÛËÌ·ÓÙÈÎfiÙËÙ· (¶›Ó·Î·˜ 3). ¶ÂÚ·ÈÙ¤Úˆ ‰Â, Ë ÔÏ˘·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ¤‰ÂÈÍ ˆ˜ Ì›· ¿ÓÔ‰Ô˜ 10 ÌÔÓ¿‰ˆÓ ÛÙË ‚·ıÌÔÏÔÁ›· Ù‹ÚËÛ˘ ªÂÛÔÁÂȷ΋˜ ‰È·ÙÚÔÊ‹˜, Û¯ÂÙÈ˙fiÙ·Ó Ì Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÔÍÂȉˆÌ¤Ó˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 22 mg/dl
(95% CI: 8- 36, p = 0,04) Î·È ·ÊÔ‡ ›¯Â ÚÔËÁËı› ¤ÏÂÁ¯Ô˜ Ù˘ ËÏÈΛ·˜, ÙÔ˘ ʇÏÔ˘, ÙÔ˘ ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜, ÙÔ˘ ηӛÛÌ·ÙÔ˜ Î·È Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ Û˘ÌÌÂÙ¯fiÓÙˆÓ (ÛÙÔȯ›· Ô˘ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3). ∏ ÂÚ·ÈÙ¤Úˆ ·Ó¿Ï˘ÛË ÙˆÓ ÔÌ¿‰ˆÓ ÙˆÓ ÙÚÔÊ›ÌˆÓ (Ô˘ ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔÓ ¶›Ó·Î· 3) ¤‰ÂÈÍ fiÙÈ Û˘ÁÎÚÈÓfiÌÂÓÔÈ Ì ·˘ÙÔ‡˜ Ô˘ ·Ó¤ÊÂÚ·Ó ÌˉÂÓÈ΋ η-
¶›Ó·Î·˜ 3: ∂›Â‰· ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ Û ۯ¤ÛË Ì ÙËÓ Ù‹ÚËÛË Ù˘ ªÂÛÔÁÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ ªÂÛÔÁÂȷ΋ ‰È·ÙÚÔÊ‹
«¢˘ÙÈÎÔ‡ Ù‡Ô˘» ‰È·ÙÚÔÊ‹
ÕÓ‰Ú˜ °˘Ó·›Î˜ ÕÓ‰Ú˜ °˘Ó·›Î˜
p
√ÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË (TC) (mg/dl)
200±44 199±44 197±45
192±39 0,224
∆ÚÈÁÏ˘ÎÂÚ›‰È· Tg (mg/dl)
143±32 107±32 135±36
101±27 0,114
HDL-¯ÔÏËÛÙÂÚfiÏË (mg/dl) LDL-¯ÔÏËÛÙÂÚfiÏË (mg/dl)
20
40
60
80
100
∏ÏÈΛ·
∏ÏÈΛ·
43±15
52±14
44±14
54±13 0,723
130±44 125±44 127±45
120±39 0,233
√ÍÂȉˆÌ¤ÓË LDL (mg/dl)
65±23
56±25
75±26
62±23 0,002
§ÈÔÚˆÙ½ÓË (·) Lp(a) (mg/dl)
19±18
21±17
16±15
17±17 0,569
√È ÙÈ̤˜ P ÚÔ‹Ïı·Ó ·fi ÙËÓ Û‡ÁÎÚÈÛË ·ÙfiÌˆÓ «ÂÁÁ‡ÙÂÚ·» ÛÙË ªÂÛÔÁÂȷ΋ ‰È·ÙÚÔÊ‹ ÚÔ˜ ÂΛӷ Ô˘ ˘ÈÔıÂÙÔ‡Ó ¤Ó· ÌÔÓÙ¤ÏÔ ‰È·ÙÚÔÊ‹˜ ÈfiÙÂÚÔ «¢˘ÙÈÎÔ‡ Ù‡Ô˘» Î·È ÂÓÒ ¤¯Ô˘Ó ÏËÊı› ˘fi„Ë ÔÈ ÂȉڿÛÂȘ ÙÔ˘ ʇÏÔ˘, ËÏÈΛ·˜, ‰Â›ÎÙË Ì¿˙·˜ ÛÒÌ·ÙÔ˜, ηӛÛÌ·ÙÔ˜, ÌfiÚʈÛ˘ Î·È Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜.
ٷӿψÛË ÔÛÚ›ˆÓ, ·˘ÙÔ› Ô˘ ‰‹ÏˆÓ·Ó ηٷӿψÛË Û˘¯ÓfiÙÂÚË ·fi 3 ÊÔÚ¤˜ ÙËÓ Â‚‰ÔÌ¿‰· (Î·È ‚Ú›ÛÎÔÓÙ·Ó ÏÔÈfiÓ, ÛÙÔ ˘„ËÏfiÙÂÚÔ ÙÂÙ·ÚÙËÌfiÚÈÔ Î·Ù·Ó¿ÏˆÛ˘ fiÛÚȈÓ) ›¯·Ó ηٿ 19% ¯·ÌËÏfiÙÂÚ· ›‰· LDL ¯ÔÏËÛÙÂÚfiÏ˘ (∂ÈÎfiÓ· 2, p = 0,04) Î·È Î·Ù¿ 6% ˘„ËÏfiÙÂÚ· ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘ (p = 0,03). ∂›Û˘, Ë ÚfiÛÏË„Ë ÊÚÔ‡ÙˆÓ Î·È Ï·¯·ÓÈÎÒÓ Û˘Û¯ÂÙ›ÛÙËΠ̛̠ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 13% (p = 0,04), ÙˆÓ ÂȤ‰ˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ηٿ 20% (p = 0,02) Î·È ¿ÓÔ‰Ô ÙˆÓ ÂȤ‰ˆÓ HDL ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 8% (p = 0,03). ∫·ÙfiÈÓ, ÂÈÎÂÓÙÚÒÛ·Ì ÙÔ ÂӉȷʤÚÔÓ Ì·˜ ÛÙÔ˘˜ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ ÂΛÓÔ˘˜ Ô˘ ‚Ú›ÛÎÔÓÙ·Ó ˘fi ˘ÔÏÈȉ·ÈÌÈ΋ Ê·Ú̷΢ÙÈ΋ ·ÁˆÁ‹ Î·È ÙËÚÔ‡Û·Ó ·Ú¿ÏÏËÏ· ÙË ªÂÛÔÁÂȷ΋ ‰È·ÙÚÔÊ‹ (Ù· ÛÙÔȯ›· ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 3). ¢È·ÈÛÙÒÛ·Ì ˆ˜ Ô ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˜ Û˘Ó‰˘·ÛÌfi˜ Û¯ÂÙÈ˙fiÙ·Ó Ì Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ ηٿ 9% (p = 0,04). √È Û˘ÌÌÂÙ¤¯ÔÓÙ˜ Ô˘ ÙËÚÔ‡Û·Ó ÙË ªÂÛÔÁÂȷ΋ ‰È·ÙÚÔÊ‹
7
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
∂ÈÎfiÓ· 2. ∂›Â‰· LDL – ¯ÔÏËÛÙÂÚfiÏ˘ Î·È Î·Ù·Ó¿ÏˆÛË ÔÛÚ›ˆÓ. P=0,04 P=0,04
LDL - ¯ÔÏËÛÙÂÚfiÏË (mg/dl)
150 139± 140
132± 130 120 113± 110 100 K·Ì›·
1-2
>3
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Î·È ÂÏ¿Ì‚·Ó·Ó ·Ú¿ÏÏËÏ· ÛÙ·Ù›ÓË Â›¯·Ó ηٿ ̤ÛÔ fiÚÔ 19% ¯·ÌËÏfiÙÂÚ· ›‰· LDL ¯ÔÏËÛÙÂÚfiÏ˘ (p = 0,021) Î·È 32% ¯·ÌËÏfiÙÂÚ· ›‰· ÔÍÂȉˆÌ¤Ó˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ (p < 0,001) Û ۇÁÎÚÈÛË Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ ÂÏ¿Ì‚·Ó·Ó ·ÁˆÁ‹ Î·È ·ÎÔÏÔ˘ıÔ‡Û·Ó, ηٿ Ùˆ Ï›ÛÙÔÓ, Ì›· « ¢˘ÙÈÎÔ‡ Ù‡Ô˘» ‰È·ÙÚÔÊ‹. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› ˆ˜ ÔÈ ·Ú·ÙËÚËı›Û˜ ÌÂÈÒÛÂȘ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚ˜ Û ۯ¤ÛË Ì ÙȘ ÌÂÈÒÛÂȘ Ô˘ ÂÈÙ‡¯ıËÎ·Ó ÌfiÓÔ Ì ‰›·ÈÙ· ‹ ÌfiÓÔ Ì ÛÙ·Ù›ÓË (p < 0,05). ∏ ›‰Ú·ÛË ÙÔ˘ ·Ú·¿Óˆ Û˘Ó‰˘·ÛÌÔ‡ ÛÙ· ˘fiÏÔÈ· ÏÈ›‰È· ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ™Â ·˘Ùfi ÙÔ ÛËÌ›Ô, Ú¤ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ Ë ·Ó·ÁˆÁ‹ ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ì·˜ ÛÙÔÓ ÁÂÓÈÎfi ÏËı˘ÛÌfi ‰ÂÓ ÌÔÚ› Ó· Û˘Ì‚Â› ¯ˆÚ›˜ ÂÈʇϷÍË. ŒÓ·˜ ·fi ÙÔ˘˜ ‚·ÛÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Â›Ó·È ÙÔ Ì¤ÙÚÈÔ ÔÛÔ-
ÛÙfi Û˘ÌÌÂÙÔ¯‹˜ (68%), ÙÔ ÔÔ›Ô Â›Ó·È ÌÂÓ ·Ô‰ÂÎÙfi ÁÈ· ÏËı˘ÛÌȷΤ˜ ÌÂϤÙ˜, fiˆ˜ Ë ·ÚÔ‡Û·, ·ÏÏ¿ ÂÈÙÚ¤ÂÈ ÙËÓ ¤ÎÊÚ·ÛË ˘Ôı¤ÛÂˆÓ fiÙÈ Ô ÙÚfiÔ˜ ˙ˆ‹˜ ·˘ÙÒÓ Ô˘ ·Ô‰¤¯ÙËÎ·Ó Ó· Û˘ÌÌÂÙ¿Û¯Ô˘Ó Î·È ·˘ÙÒÓ Ô˘ ‰ÂÓ Û˘ÌÊÒÓËÛ·Ó, ÂӉ¯Ô̤ӈ˜ Ó· Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi˜. ŒÓ·˜ ·ÎfiÌË ÂÚÈÔÚÈÛÌfi˜ Â›Ó·È Ô Û˘Á¯ÚÔÓÈÎfi˜ ۯ‰ȷÛÌfi˜ Ù˘ ÌÂϤÙ˘. ∂Ô̤ӈ˜, Ù· ·Ú·ÙËÚÔ‡ÌÂÓ· ÔʤÏË ·fi ÙË ªÂÛÔÁÂȷ΋ ‰È·ÙÚÔÊ‹ ÛÙ· ›‰· ÔÍÂȉˆÌ¤Ó˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘, ‹ Ë Â›‰Ú·ÛË Ù˘ Ê˘ÛÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÛÙ· ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘ ı· Ú¤ÂÈ ÂÚ·ÈÙ¤Úˆ Ó· ‰ÈÂÚ¢ÓËıÔ‡Ó ÌÂ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜.
™Àª¶∂ƒ∞™ª∞ ¶·Ú¿ ÙÔ˘˜ ÚÔ·Ó·ÊÂÚfiÌÂÓÔ˘˜ ÂÚÈÔÚÈÛÌÔ‡˜, Ë ·ÚÔ‡Û· ÌÂϤÙË
·ÔÎ¿Ï˘„ fiÙÈ ÛÙË ¯·Ú·˘Á‹ ÙÔ˘ 21Ô˘ ·ÈÒÓ·, Ì›· ·ÍÈÔÛËÌ›ˆÙË ÌÂÚ›‰· ·Ó‰ÚÒÓ Î·È Á˘Ó·ÈÎÒÓ ¤¯Ô˘Ó ›‰· ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ ¿Óˆ ·fi Ù· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. µ·ÛÈṲ̂ÓÔÈ ÛÙ· Â˘Ú‹Ì·Ù¿ Ì·˜, ÌÔÚԇ̠ӷ ÂÈοÛÔ˘Ì fiÙÈ ÂÚ›Ô˘ ÙÚ›· ÂηÙÔÌ̇ÚÈ· ŒÏÏËÓ˜ ¤¯Ô˘Ó ˘„ËÏ¿ ›‰· ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘. ∂ÈÚfiÛıÂÙ·, ϤÔÓ ÙÔ˘ ÂÓfi˜ ÛÙÔ˘˜ ÙÚÂȘ Û˘ÌÌÂÙ¤¯ÔÓÙ˜ Ì ›‰· ÏÈȉ›ˆÓ ·›Ì·ÙÔ˜ ¿Óˆ ·fi Ù· Ê˘ÛÈÔÏÔÁÈο, ‰ÂÓ Â›¯·Ó ›ÁÓˆÛË Ù˘ ηٿÛÙ·Û‹˜ ÙÔ˘˜, ÂÓÒ ÌfiÓÔ Ô ¤Ó·˜ ÛÙÔ˘˜ ‰‡Ô ·fi fiÛÔ˘˜ ÂÏ¿Ì‚·Ó·Ó ˘ÔÏÈȉ·ÈÌÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÙ‡¯·ÈÓ·Ó Ù· ηıÔÚÈṲ̂ӷ ˆ˜ ÂÈı˘ÌËÙ¿ ›‰· ÏÈȉ·ÈÌ›·˜. ŸÛÔÓ ·ÊÔÚ¿ ÛÙËÓ Â›‰Ú·ÛË ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ Û˘ÓËıÂÈÒÓ, ·ÚfiÙÈ ÌfiÓË Ë Ù‹ÚËÛË Ù˘ ªÂÛÔÁÂȷ΋˜ ‰È·ÙÚÔÊ‹˜ ‰ÂÓ ÂËÚ¤·Û ٷ ÏÈ›‰È· ·›Ì·ÙÔ˜ (Ì ÂÍ·›ÚÂÛË ÙËÓ ÔÍÂȉˆÌ¤ÓË LDL ¯ÔÏËÛÙÂÚfiÏË), Ô Û˘Ó‰˘·ÛÌfi˜ ·˘Ù‹˜ Ì ıÂڷ›· Ì ÛÙ·Ù›ÓË Â¤ÊÂÚ ¤Ó· Û˘ÓÂÚÁÈÎfi ˘ÔÏÈȉ·ÈÌÈÎfi ·ÔÙ¤ÏÂÛÌ·. µ·ÛÈ˙fiÌÂÓÔÈ ÛÙËÓ ÈÛ¯˘Ú‹ Èı·ÓfiÙËÙ·, Ì›· Ù¤ÙÔÈ· ÙÚÔÔÔ›ËÛË ÙˆÓ ÂȤ‰ˆÓ ÏÈȉ›ˆÓ ÙÔ˘ ·›Ì·ÙÔ˜ Ó· Â›Ó·È ÂˆÊÂÏ‹˜, ȉ›ˆ˜, ÁÈ· ÂΛÓÔ˘˜ Ì ˘„ËÏfiÙÂÚÔ Î›Ó‰˘ÓÔ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘, ÚÔÙ›ÓÔ˘Ì ˆ˜ Ô˘ÛÈÒ‰Ë ÙË ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡ ÁÈ· ÏÈȉ·ÈÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ Î·È ıˆÚԇ̠ÛÎfiÈÌÔ ·˘Ù‹ Ó· ·ÎÔÏÔ˘ıËı› ·fi ÂÓÂÚÁËÙÈΤ˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ ·ÚÂÌ‚¿ÛÂȘ16.
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Gotto AM Jr. Lipid and lipoprotein disorders. In: Pearson TA, Criqui MH, Luepker RV, Oberman A, Wilson M, eds. Primer in Preventive Cardiology. Dallas, Tex: American Heart Association; 1994: 107-129. Ginsberg HN. Lipoprotein metabolism and its relationship to atherosclerosis. Med Clin North Am 1994;78:1-20. Wilson PWF, Abbott RD, Castelli WP. High density lipoprotein cholesterol and mortality. Arteriosclerosis 1988;8:737-741. Executive summary of the third report of the National Cholesterol Educational Program Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. JAMA 2001; 285: 19: 2486-2497. Gran B. Major differences in cardiovascular risk indicators by educational status. Results from a population based screening program. Scand J Soc Med 1995; 23:9-16. Keys A, Menotti A, Karvonen MJ. The diet and 15-year death rate in the Seven Countries Study. Am J Epidemiol 1986; 124: 903 – 915 Denke M. Cholesterol lowering diets. A re-
view of evidence. Arch Int Med 1995: 155; 17-26. 8. Trichopoulou A, Kouris-Blazos A, Wahlqvist M, Gnardellis C, Lagiou P, Polychronopoulos E, Vassilakou T, Lipworth L, Trichopoulos D. Diet and overall survival in elderly people. Brit Med J 1995; 311: 1457 – 1460. 9. Kafatos A, Diacatou A, Voukiklaris G, Nikolakakis N, Vlachonikolis J, Kounali D, Mamalakis G, Dontas A.S. Heart disease risk-factor status and dietary changes in the Cretan population over the past 30 years: the Seven Countries Study. Am J Clin Nutr 1997; 65:1882-1886. 10. de Lorgeril M., Salen, P., Martin J.-L., Monjaud I,. Delaye J., Mamelle N., Mediterranean diet, traditional risk factors and the rate of cardiovascular complications after myocardial infarction. Final report of the Lyon Diet Heart Study. Circulation 1999; 99: 779-785. 11. Panagiotakos DB, Pitsavos H, Chrysohoou C, Skoumas J, Papadimitriou L, Stefanadis C, Toutouzas PK. Status and Management of Hypertension, in Greece; the role of the adoption of Mediterranean Diet:
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the ATTICA study. J Hypertens 2003;21: 1483-1489. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 2003;348: 2599-2608. Trichopoulou A, From Research to Education: The Greek experience. Nutrition 2000; 16: 528 - 531. Willett WC, Sacks F, Trichopoulou A, Drescher G, Ferro-Luzzi A, Helsing E, Trichopoulos D. Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr 1995; 6:1402S-1406S. Pitsavos C, Chrysohoou C, Panagiotakos DB, Skoumas J, Zeimbekis A, Kokkinos P, Stefanadis C, Toutouzas PK. Association of Leisure-time Physical Activity on Inflammation Markers (C-Reactive Protein, White-blood Cell count, serum Amyloid A and Fibrinogen), in Healthy subjects (from the ATTICA Study). Am J Cardiol 2003:91: 368-370. Shepherd J. Economics of lipid lowering in primary prevention: lessons from the West of Scotland Coronary Prevention Study. Am J Cardiol 2001; 87: 19-22.
¶A£OºY™IO§O°IA
∏ ∂ÌÊ¿ÓÈÛË ÃÚfiÓÈ·˜ ¡ÂÊÚÈ΋˜ ¡fiÛÔ˘ Û ∞ÛıÂÓ›˜ Ì π‰ÈÔ·ı‹ À¤ÚÙ·ÛË ˘fi ∞ÁˆÁ‹ µ∞™π§∂π√™ ™∞√À°∫√™, ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ µ’ ¶·ıÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ
ªøÀ™∏™ ∂§π™∞º, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜, ¢È¢ı˘ÓÙ‹˜ µ’ ¶·ıÔÏÔÁÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ ¡ÔÛÔÎÔÌ›Ԣ πˆ·ÓÓ›ÓˆÓ
¯ÂÈ ‰È·ÈÛÙˆı› ·fi ÌÂϤÙ˜ fiÙÈ Ë È‰ÈÔ·ı‹˜ ˘¤ÚÙ·ÛË, ·ÎfiÌË Î·È fiÙ·Ó ·ÓÙÈÌÂÙˆ›˙ÂÙ·È Ê·Ú̷΢ÙÈο, Û˘Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ÂÌÊ¿ÓÈÛË ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘1,2. ™ÙȘ ∏.¶.∞. ˘ÔÏÔÁ›˙ÂÙ·È fiÙÈ ÂÚ›Ô˘ 5,5 ÂηÙÔÌ̇ÚÈ· ¿ÙÔÌ· ÂÌÊ·Ó›˙Ô˘Ó Î¿ÔÈÔ˘ ‚·ıÌÔ‡ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∆Ô 70% ·˘ÙÒÓ ÙˆÓ ·ÙfiÌˆÓ ¤¯ÂÈ ·˘ÍË̤ÓË ·ÚÙËÚȷ΋ ›ÂÛË. Œ¯ÂÈ ÂӉȷʤÚÔÓ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ 27% ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË Î·È ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ›¯·Ó ÛÙÔ ·ÚÂÏıfiÓ Ú˘ıÌÈṲ̂ÓË ˘¤ÚÙ·ÛË (·ÚÙËÚȷ΋ ›ÂÛË ÌÈÎÚfiÙÂÚË ·fi 140/90 mmHg)3. ™‡Ìʈӷ Ì ÙȘ ÓÂfiÙÂÚ˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜4 ˆ˜ ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ˜ ÔÚ›˙ÂÙ·È Â›ÙÂ Ë ·ÚÔ˘Û›· ÓÂÊÚÈ΋˜ ‚Ï¿‚˘ ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 3 ÌËÓÒÓ Ì ‹ ¯ˆÚ›˜ Ì›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR), ›ÙÂ Ë ÂÏ¿ÙÙˆÛË ÙÔ˘ GFR<60 ml/min/1,73 m2 ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 3 ÌËÓÒÓ Ì ‹ ¯ˆÚ›˜ ÓÂÊÚÈ΋ ‚Ï¿‚Ë. ∏ ·ÚÔ˘Û›· ÓÂÊÚÈ΋˜ ‚Ï¿‚˘ ÂȂ‚·ÈÒÓÂÙ·È Â›Ù Ì ‚ÈÔ„›· ÓÂÊÚÔ‡, ›Ù Ì ÙËÓ ·ÚÔ˘Û›· ‰È·Ù·Ú·¯ÒÓ Û ·ÂÈÎÔÓÈÛÙÈΤ˜ ÌÂıfi‰Ô˘˜, ›Ù Ì ÂÚÁ·ÛÙËÚÈ·ÎÔ‡˜ ‰Â›ÎÙ˜ (.¯. Ë ·ÚÔ˘Û›· ÚˆÙÂ˚ÓÔ˘Ú›·˜). ∏ ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Á›ÓÂÙ·È Î˘Ú›ˆ˜ Ì ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ‰Â›ÎÙË ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR), Ë ÔÔ›· ÛÙËÓ Ú¿ÍË ÂÎÙÈÌ¿Ù·È ·fi ÙËÓ Î¿ı·ÚÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘4. ∏ ÙÂÏÂ˘Ù·›· ÌÔÚ› Ó· ˘ÔÏÔÁÈÛı› ›Ù ÌÂÙ¿ ·fi 24ˆÚË Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ, ›Ù Ì ‚¿ÛË ÙËÓ ÎÚ·ÙÈÓ›ÓË ÙÔ˘ ÔÚÔ‡ Î·È ÙËÓ Â͛ۈÛË CockcroftGault5 ‹ ÙËÓ Â͛ۈÛË MDRD6 (¶›Ó·Î·˜ 1). ªÂ ‚¿ÛË ÙÔ Ú˘ıÌfi ÛÂÈÚ·Ì·-
Œ
¶›Ó·Î·˜ 1: ÀÔÏÔÁÈÛÌfi˜ ÙÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ Ì ‚¿ÛË ÙËÓ ÎÚ·ÙÈÓ›ÓË ÙÔ˘ ÔÚÔ‡* ñ ∂͛ۈÛË Cockcroft-Gault: (140-ËÏÈΛ·) à ‚¿ÚÔ˜ ÛÒÌ·ÙÔ˜ Ccr(ml/min)=
X (0,85, Û Á˘Ó·›Î˜) 72 à Scr
ñ ∂͛ۈÛË MDRD: GFR(ml/min/1,73 m2) =186 X (Scr)1.154 X (∏ÏÈΛ·) 0.203 X (0.742 Û Á˘Ó·›Î˜) Scr = ÎÚ·ÙÈÓ›ÓË ÔÚÔ‡, Ccr = οı·ÚÛË ÎÚ·ÙÈÓ›Ó˘ * ™ÙȘ ·Ú·¿Óˆ ÂÍÈÛÒÛÂȘ, Ë Scr Â›Ó·È Û mg/dl, Ë ËÏÈΛ· Û ¤ÙË Î·È ÙÔ ‚¿ÚÔ˜ Û kg
¶›Ó·Î·˜ 2: ™Ù¿‰È· ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘. ™Ù¿‰ÈÔ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘
GFR(ml/min/1,73 m2)
¶ÂÚÈÁÚ·Ê‹
1
¡ÂÊÚÈ΋ ‚Ï¿‚Ë ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ‹ ·˘ÍË̤ÓÔ GFR
≥90
2
¡ÂÊÚÈ΋ ‚Ï¿‚Ë Ì ‹È· Ì›ˆÛË ÙÔ˘ GFR
60-89
3
ª¤ÙÚÈ· Ì›ˆÛË ÙÔ˘ GFR
30-59
4
™Ô‚·Ú‹ Ì›ˆÛË ÙÔ˘ GFR
15-29
5
¡ÂÊÚÈ΋ ·Ó¿ÚÎÂÈ·
<15 ‹ ·ÈÌÔοı·ÚÛË
GFR = Ú˘ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘
ÙÈ΋˜ ‰È‹ıËÛ˘, Ô˘ ˘ÔÏÔÁ›˙ÂÙ·È fiˆ˜ ·Ó·Ê¤ÚıËΠ·Ú·¿Óˆ, Á›ÓÂÙ·È Ë ÛÙ·‰ÈÔÔ›ËÛË Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘4 ÛÙ· ÛÙ¿‰È· Ô˘ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. ¶ÔÏϤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÔÔÈÔ˘‰‹ÔÙ ‚·ıÌÔ‡ ¤ÎÙˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û˘Óԉ‡ÂÙ·È ·fi ·ÓÙ›ÛÙÔÈ¯Ë ·‡ÍËÛË, ηٿ ÁÚ·ÌÌÈÎfi ÙÚfiÔ, ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂÈ·ÎÔ‡ Û˘Ì‚¿Ì·ÙÔ˜7. ∏ ÌÂϤÙË Hypertension Detect and Follow Up Program8 ¤‰ÂÈÍ ÁÈ· ÚÒÙË ÊÔÚ¿ ÙËÓ ÈÛ¯˘Ú‹ ÚÔÁÓˆÛÙÈ΋ ·Í›· Ù˘ ·˘ÍË̤Ó˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÂÓÙ·ÂÙ‹ Î·È ÔÎÙ·ÂÙ‹ ıÓËÛÈÌfiÙËÙ·. ÕÏϘ ÌÂ-
ϤÙ˜ Ô˘ ·ÎÔÏÔ‡ıËÛ·Ó ÂȂ‚·›ˆÛ·Ó ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô Ú˘ıÌfi˜ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ ·ÔÙÂÏ› ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÔ‡ ÂÂÈÛÔ‰›Ô˘ Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÔÈ ÌÂϤÙ˜ Hypertension Optimal Treatment (HOT)9, Intervention as a Goal in Hypertension Treatment (INSIGHT)10, Systolic Hypertension in Europe (SYST-EUR)11, Systolic Hypertension in China (SYST-CHINA)12, Atherosclerosis Risk on Communities (ARIC)13 Î·È HOORN14. ∏ ηıÔÏÈ΋ ·Ô‰Ô¯‹ Ù˘ ÌÂȈ̤Ó˘ GFR ˆ˜ ·Ú¿ÁÔÓÙ· ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚÔ·ÙÂÈ Â›Û˘ Î·È ·fi ÙËÓ ÂÓۈ̿وÛË
9
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ˆ˜ ‚·ÛÈ΋˜ ·Ú·Ì¤ÙÚÔ˘ ÁÈ· ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ ÛÙȘ ÚfiÛÊ·Ù˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘¤ÚÙ·Û˘. ™‡Ìʈӷ Ì ÙËÓ ¤‚‰ÔÌË ·Ó·ÊÔÚ¿ Ù˘ Joint National Committee (JNC-7), Ë ÌÈÎÚÔ·Ï‚Ô˘ÌÈÓÔ˘Ú›· Î·È Ë Ì›ˆÛË ÙÔ˘ Ú˘ıÌÔ‡ Ù˘ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ (GFR < 60 ml/min/1,73 m2) Â›Ó·È ·Ú¿ÌÂÙÚÔÈ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÂÈÛÔ‰›ˆÓ15. ∂›Û˘, Ú¤ÂÈ Ó· ÂÈÛËÌ·Óı› fiÙÈ Ë ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ˜ Û˘Ó˘¿Ú¯ÂÈ Û˘¯Ó¿ Î·È Û˘Û¯ÂÙ›˙ÂÙ·È Ì ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (¶›Ó·Î·˜ 3)16-27. ∂ÈÚfiÛıÂÙ·, Ë Ì›ˆÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ·ÔÙÂÏ› ÈÛ¯˘Úfi ·Ú¿ÁÔÓÙ· Úfi‚Ï„˘ Ù˘ ÎÏÈÓÈ΋˜ ÔÚ›·˜ ·ÛıÂÓÒÓ Ì ηډȷο ÂÂÈÛfi‰È· Î·È Û˘ÁÎÂÎÚÈ̤ӷ Û ·ÛıÂÓ›˜ Ì Ôͤ· ÛÙÂÊ·ÓÈ·›· Û‡Ó‰ÚÔÌ·28, ηډȷ΋ ·Ó¿ÚÎÂÈ·29, ÌÂÙ¿ ÛÙÂÊ·ÓÈÔÁÚ·Ê›·30, Û ¯ÂÈÚÔ˘ÚÁÈΤ˜ ÂÂÌ‚¿ÛÂȘ31, ηıÒ˜ Î·È Û ·ÛıÂÓ›˜ Ô˘ ÂÈÛ¿ÁÔÓÙ·È Û ÌÔÓ¿‰Â˜ ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜32. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ¯ÚfiÓÈ·˜ ÓÂÊÚÈ΋˜ ÓfiÛÔ˘ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· Î·È ÙÔ˘ ·˘ÍË̤ÓÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô˘ ·˘Ù‹ Û˘Ó¿ÁÂÙ·È Û˘ÓÈÛÙ¿Ù·È ˘ÁÈÂÈÓԉȷÈÙËÙÈ΋ ·Ú¤Ì‚·ÛË, Ë ÔÔ›· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ¿ÌÂÛË ‰È·ÎÔ‹ ÙÔ˘ ηӛÛÌ·ÙÔ˜, ÙËÓ ·ÒÏÂÈ· ۈ̷ÙÈÎÔ‡ ‚¿ÚÔ˘˜ Î·È ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË Ù˘ ηٷӿψÛ˘ ·Ï·ÙÈÔ‡. ∞·ÈÙ›ٷÈ, ›Û˘, ·˘ÛÙËÚfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ (Èı·ÓÒ˜ Û ›‰· < 125/75 mmHg) Ì ÙË ¯Ú‹ÛË Û˘Ó‰˘·ÛÌÔ‡
¶›Ó·Î·˜ 3: ¶·Ú¿ÁÔÓÙ˜ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘. ñ
∞˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Lp(a)
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∞ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘
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∞˘ÍË̤ÓÔ ÔÍÂȉˆÙÈÎfi stress
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∞˘ÍË̤ӷ ›‰· Ô˘ÚÈÎÔ‡ ÔͤԘ ÛÙÔÓ ÔÚfi
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∞˘ÍË̤ÓË ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ Û˘Ì·ıËÙÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜
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∞‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ¢ԉÒÓÔ˘Ó ÙË ÊÏÂÁÌÔÓ‹ (CRP, IL-6, ÈÓˆ‰ÔÁfiÓÔ)
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·ÓÙÈ˘ÂÚÙ·ÛÈÎÒÓ Ê·Ú̿ΈÓ15,33. À¿Ú¯Ô˘Ó ‚¿ÛÈ̘ ÂӉ›ÍÂȘ fiÙÈ Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ··ÈÙÂ›Ù·È Ë ¯ÔÚ‹ÁËÛË ÂÓfi˜ ·Ó·ÛÙÔϤ· ÙÔ˘ ÌÂÙ·ÙÚÂÙÈÎÔ‡ ÂÓ˙‡ÌÔ˘ ‹ ÂÓ·ÏÏ·ÎÙÈο ÂÓfi˜ ·ÓÙ·ÁˆÓÈÛÙ‹ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ ·ÁÁÂÈÔÙ·Û›Ó˘ II, ηıÒ˜ ·˘Ù¤˜ ÔÈ Î·ÙËÁÔڛ˜ Ê·ÚÌ¿ÎˆÓ ‚ÂÏÙÈÒÓÔ˘Ó ÙË ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Û ·ÛıÂÓ›˜ Ì ÓÂÊÚÔÛÎÏ‹Ú˘ÓÛË34,35. ∂ÈÚfiÛıÂÙ·, Û‡Ìʈӷ Î·È Ì ÙȘ ÓÂfiÙÂÚ˜ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ Î·È ÂÊfiÛÔÓ ÔÈ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ Â›Ó·È ¿ÙÔÌ· ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ, ıˆÚÂ›Ù·È ‰fiÎÈÌË Ë Ì›ˆÛË Ù˘ ÙÈÌ‹˜ ÛÙfi¯Ô˘ ÙfiÛÔ ÁÈ· ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË, fiÛÔ Î·È ÁÈ· ÙËÓ LDL ¯ÔÏËÛÙÂÚfiÏË. ™˘ÁÎÂÎÚÈ̤ӷ, fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÚÙËÚȷ΋ ›ÂÛË Ú¤ÂÈ Ù· ›‰¿ Ù˘ Ó· Â›Ó·È ÌÈÎÚfiÙÂÚ· ·fi 130/80 mmHg, ÂÎÙfi˜ Î·È ·Ó Û˘Ó˘¿Ú¯ÂÈ ÚˆÙÂ˚ÓÔ˘Ú›· ÌÂÁ·Ï‡ÙÂÚË ÙÔ˘ 1 gr/ 24ˆÚÔ, ÔfiÙÂ Ô ÛÙfi¯Ô˜ Ù˘ ·ÁˆÁ‹˜ Ú¤ÂÈ Ó· Â›Ó·È Â›Â‰· ·ÚÙËÚȷ΋˜ ›ÂÛ˘ <125/75 mm Hg4. ∆· ÂÈı˘ÌËÙ¿ ›‰· Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ ηıÔÚ›˙ÔÓÙ·È Û οı ÂÚ›ÙˆÛË ·fi ÙË Û˘Ó‡·ÚÍË Î·È ¿ÏÏˆÓ ·Ú·ÁfiÓÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘, ÛÙ· Ï·›ÛÈ· ÂÎÙ›ÌËÛ˘ ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ-
‰‡ÓÔ˘ ÙÔ˘ ·ÛıÂÓ‹. øÛÙfiÛÔ, Ë Û˘¯Ó‹ ·ÚÔ˘Û›· ÔÏÏ·ÏÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ Î·ıÈÛÙ¿ ÂÈı˘ÌËÙ‹ ÙË Ì›ˆÛË Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘ Û ›‰· ÌÈÎÚfiÙÂÚ· ·fi 100 mg4. ™Â ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ηıÒ˜ Î·È Û ·ÛıÂÓ›˜ Ì ÂÁηÙÂÛÙË̤ÓË Î·Ú‰È·ÁÁÂȷ΋ ÓfiÛÔ Ú¤ÂÈ ÛÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô ÚÔ˘Ù›Ó·˜ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ÂÎÙ›ÌËÛË Ù˘ ÓÂÊÚÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Ì ÙË Ì¤ÙÚËÛË Û ‰Â›ÁÌ· Ô‡ÚˆÓ ÙÔ˘ ÏfiÁÔ˘ ·Ï‚Ô˘Ì›ÓË/ÎÚ·ÙÈÓ›ÓË ‹ ÔÏÈ΋ ÚˆÙ½ÓË/ÎÚ·ÙÈÓ›ÓË Î·È Ì ÙÔÓ ˘ÔÏÔÁÈÛÌfi ÙÔ˘ Ú˘ıÌÔ‡ ÛÂÈÚ·Ì·ÙÈ΋˜ ‰È‹ıËÛ˘ ÙÔ˘ ·ÛıÂÓ‹ Ì ÙË Ì¤ÙÚËÛË Ù˘ ÎÚ·ÙÈÓ›Ó˘ ÙÔ˘ ÔÚÔ‡ Î·È ÙȘ ÂÍÈÛÒÛÂȘ Ô˘ ÚԷӷʤÚıËηÓ7 (¶›Ó·Î·˜ 1). ¶Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ ÈÛ¯˘Ú‹ ÚÔÁÓˆÛÙÈ΋ ·Í›· ¤¯ÂÈ fi¯È ÌfiÓÔ Ë ·Ï‚Ô˘ÌÈÓÔ˘Ú›· Û ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÓÂÊÚÈ΋ ÓfiÛÔ Î·È È‰ÈÔ·ı‹ ˘¤ÚÙ·ÛË ·ÏÏ¿ Î·È Ë ÔÛÔÛÙÈ·›· Ì›ˆÛ‹ Ù˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜. ¶Ú¿ÁÌ·ÙÈ, ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ ÔÔÈÔ˘‰‹ÔÙ ‚·ıÌÔ‡ Ì›ˆÛË Ù˘ ·Ï‚Ô˘ÌÈÓÔ˘Ú›·˜ ÌÂÙ·ÊÚ¿˙ÂÙ·È Û ·ÓÙ›ÛÙÔÈ¯Ô˘ ‚·ıÌÔ‡ Ì›ˆÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘36.
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National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis 2002; 39(2 suppl 1):S1-S266
5.
Cockroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31-41
µÈ‚ÏÈÔÁÚ·Ê›·
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1.
Vuppputuri S, Batuman V, Muntner P, et al. Effect of blood pressure on early decline in kidney function among hypertensive men. Hypertension 2003;42: 1144-1149
2.
The HOPE investigators. Renal insufficiency as a predictor of cardiovascular outcomes and the impact of Ramipril: The HOPE randomized trial. Ann Intern Med 2001;134:629-636
Coresh J, Wei GL, McQuillan G, Brancati FL, Levey AS, Jones C, et al. Prevalence of high blood pressure and elevated serum creatinine level in the United States: Findings from the third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2001;161:1207-1216
¶∞£√ºÀ™π√§√°π∞ 6.
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Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461470 Sarnak MJ, Levey AS, Schollwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease. A statement from the American Heart Association councils on kidney in cardiovascular disease, high blood pressure research, clinical cardiology, and epidemiology and prevention. Circulation 2003;108:2154-2169 Shulman NB, Ford CE, Hall WD, et al. Prognostic value of serum creatinine and effect of treatment of hypertension on renal function. Results from the Hypertension Detection and Follow-up Program. Hypertension 1989;13(5 suppl.):180-193 Ruilope LM, Salvetti A, Jamerson K, et al. Renal function and intensive lowering of blood pressure in the hypertensive subjects of the Hypertension Optimal Treatment (HOT) study. J Am Soc Nephrol 2001;12:219-225
10. Ruilope LM, Palmer C, de Leeuw P, et al. Evaluation of different parameters of renal function as predictors of primary outcome in the INSIGHT study (Abstract). J Hypertens 2001;19(Suppl.2): S223 11. De Leeuw P, Thijs L, Birkenhager WH, et al. Prognostic significance of renal function in elderly patients with isolated systolic hypertension: results from SystEur trial. J Am Soc Nephrol 2002;13: 2213-2222
15. Chobanian A, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA 2003; 289:2560-2572 16. Kronenberg F, Kuen E, Ritz E, et al. Lipoprotein(a) serum concentrations and apolipoprotein(a) phenotypes in mild and moderate renal failure. J Am Soc Nephrol 2000;11:105-115 17. Fliser D, Pacini G, Engelleiter R, et al. Insulin resistance and hyperinsulinemia are already present in patients with incipient renal disease. Kidney Int 1998;53:1343-1347 18. Kato Y, Hayashi M, Ohno Y, et al. Mild renal dysfunction is associated with insulin resistance in chronic glomerulonephritis. Clin Nephrol 2000;54:366-373 19. Ribstein J, Du Cailar G, Mimran A. Glucose tolerance and age-associated decline in renal function of hypertensive patients. J Hypertens 2001;19:22572264 20. Witko-Sarsat V, Friedlander M, Nguyen, et al. Advanced oxidation protein products as novel mediators of inflammation and monocyte activation in chronic renal failure. J Immunol 1998;161:25242532 21. Minuz P, Patrignani P, Gaino S, et al. Increased oxidative stress and platelet activation in patients with hypertension and renovascular disease. Circulation 2002;106:2800-2805 22. Johnson RJ, Kang DH, Feig D, et al. Is there a pathogenetic role for uric acid in hypertension and cardiovascular and renal disease? Hypertension 2003;41: 1183-1190
12. Wang JG, Staessen JA, Fagard RH, et al. Prognostic significance of serum creatinine and uric acid in older Chinese patients with isolated systolic hypertension. Hypertension 2001;37:10691074
23. Tinnuci T, Abrahao SB, Santello JL, Mion D Jr. Mild chronic renal insufficiency induces sympathetic overactivity. J Hum Hypertens 2001;15:401-406
13. Manjunath G, Tighiouart H, Ibrahim H, et al. Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community. J Am Coll Cardiol 2003;41:47-55
24. Shlipak MG, Fried LF, Crump C, et al. Elevations of inflammatory and procoagulant biomarkers in elderly persons with renal insufficiency. Circulation 2003;107: 87-92
14. Henry RM, Kostense PJ, Bos G, et al. Mild renal insufficiency is associated with increased cardiovascular mortality: The HOORN Study. Kidney Int 2002;62: 1402-1407
25. Zoccali C, Menon V, Wang X, et al. Relationship between C-reactive protein, albumin and cardiovascular disease in patients with chronic kidney disease. Am J Kidney Dis 2003;42:44-52 26. De Jong PE, Verhave JC, Pinto-Sietsma SJ, Hillege HL, for the PREVEND study
group. Obesity and target organ damage: the kidney. Int J Obesity 2002; 26 (Suppl. 4):S21-S24 27. Pinto-Sietsma SJ, Navis G, Janssen WMT, et al. for the PREVEND study group. A central body fat distribution is related to renal function impairment, even in lean subjects. Am J Kidney Dis 2003;41:733-741 28. Mc Cullough PA. Why is chronic kidney disease the "spoiler" for cardiovascular outcomes? J Am Coll Cardiol 2003;41: 725-728 29. Mahom NJ, Blackstone EH, Francis GS, et al. The prognostic value of estimated creatinine clearance alongside functional capacity in ambulatory patients with chronic congestive heart failure. J Am Coll Cardiol 2002;40:1106-1113 30. Reis SE, Olson MB, Fried L, et al. Mild renal insufficiency is associated with angiographic coronary artery disease in women. Circulation 2002;105:28262829 31. O’Brien MM, Gonzales R, Shroyer AL, et al. Modest serum creatinine elevation affects adverse outcome after general surgery. Kidney Int 2002;62:585-592 32. Clermont G, Acker CG, Angus DC, et al. Renal failure in the ICU:comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int 2002;62:986-996 33. Guidelines Committee. 2003 European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003;21:1011-1053 34. Wright JT Jr, Bakris G, Greene T, et al. for the African-American Study of Kidney Disease and Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA 2002; 288:2421-2431 35. Segura J, Campo C, Rodicio JL, Ruilope LM. ACE inhibitors and appearance of renal events in hypertensive nephrosclerosis. Hypertension 2001;38:645649 36. The Losartan Intervention for Endpoint Reduction in Hypertension Study group. Reduction in Albuminuria Translates to Reduction in Cardiovascular Events in Hypertensive Patients. Hypertension 2005; 45:198-202
11
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
¶ÔÈfi ı· ∂›Ó·È ÙÔ ∞ÓÙÈ˘ÂÚÙ·ÛÈÎfi ¶ÚÒÙ˘ ∂ÈÏÔÁ‹˜; πˆ¿ÓÓ˘ °Ô˘‰¤‚ÂÓÔ˜, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜-∫·Ú‰ÈÔÏÔÁ›·˜, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ
ÚfiÛÊ·Ù· ‰ËÌÔÛȇÙËΠÙÔ ·ÓÙÈ˘ÂÚÙ·ÛÈÎfi ÛΤÏÔ˜ Ù˘ ÌÂϤÙ˘ Anglo-Scandinavian Cardiac Outcomes Trial ÙÔ ASCOT-BPLA1. To ˘ÔÏÈȉ·ÈÌÎfi ÛΤÏÔ˜ Ù˘ ›‰È·˜ ÌÂϤÙ˘ (ASCOT- LLA) ›¯Â ‰Â›ÍÂÈ fiÙÈ Ë ¯ÔÚ‹ÁËÛË ·ÙÔÚ‚·ÛÙ·Ù›Ó˘ 10 mg Û ˘ÂÚÙ·ÛÈο ¿ÙÔÌ· ÌÂ Ê˘ÛÈÔÏÔÁÈο ‹ ÂÏ·ÊÚ¿ ·˘ÍË̤ӷ ›‰· ÔÏÈ΋˜ ¯ÔÏËÛÙÂÚfiÏ˘ (≤250 mg/dL) ÌÂÈÒÓÂÈ ÛËÌ·ÓÙÈο Ù· ηډȷÁÁÂȷο ÂÂÈÛfi‰È·.2 ™ÙÔ ·ÓÙÈ˘ÂÚÙ·ÛÈÎfi ÛΤÏÔ˜ Ù˘ ASCOT Û˘ÁÎÚ›ıËÎ·Ó ‰‡Ô Ê·Ú̷΢ÙÈΤ˜ ÛÙÚ·ÙËÁÈΤ˜. ∏ ÚÒÙË ÛÙÚ·ÙËÁÈ΋ ¯ÚËÛÈÌÔÔ›ËÛ ηÈÓÔ‡ÚÁÈ· Ê¿Ú̷η Ô˘ ÂÚÈÂÏ¿Ì‚·Ó ·ÌÏԉțÓË (5-10 mg) Î·È ·Ó ¯ÚÂÈ·˙fiÙ·Ó ÂÚÈÓ‰ÔÚ›ÏË (4-8 mg) Î·È Ë ‰Â‡ÙÂÚË ·ÙÂÓÔÏfiÏË (50-100 mg) Î·È ·Ó ¯ÚÂÈ·˙fiÙ·Ó ‰ÈÔ˘ÚËÙÈο. ¶ÂÚ›Ô˘ 20.000 ˘ÂÚÙ·ÛÈÎÔ› (›‰· ∞¶ ≥ 160/100 mmHg ¯ˆÚ›˜ ıÂڷ›· ‹ - ≥ 140/90 mmHg ˘fi ıÂڷ›·) ËÏÈΛ·˜ 40 ¤ˆ˜ 79 ÂÙÒÓ Î·È ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ·ÛıÂÓ›˜ (Ì ÙÔ˘Ï¿¯ÈÛÙÔÓ 3 ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘) ηٷÓÂÌ‹ıËÎ·Ó Ù˘¯·›· ÛÙ· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ıÂڷ¢ÙÈο Û¯‹Ì·Ù·. ∏ ÌÂϤÙË ‰È‹ÚÎÂÛ 5,4 ¯ÚfiÓÈ· Î·È ÏÈÁfiÙÂÚÔ ÙÔ˘ 2% ¯¿ıËÎ·Ó ÛÙË ·Ú·ÎÔÏÔ‡ıËÛË. ∫ÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ ·fi ÙËÓ ÌÂϤÙË ‹Ù·Ó ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, ÛÙËı¿Á¯Ë ˘fi ıÂڷ›·, ÚfiÛÊ·ÙÔ ÂÁÎÂÊ·ÏÈÎfi ÌË ÂÏÂÁ¯fiÌÂÓ˜ ·ÚÚ˘ı̛˜ Î·È Î·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ·. √È ıÂڷ¢ÙÈÎÔ› ÛÙfi¯ÔÈ ‹Ù·Ó ›‰· ∞¶ <140/90 mmHg ÁÈ· ·ÛıÂÓ›˜ ¯ˆÚ›˜ ‰È·‚‹ÙË Î·È <130/80 ÁÈ· ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË. ∏ ÌÂϤÙË ÛÙ·Ì¿ÙËÛ ÚfiˆÚ· (fiˆ˜ Î·È Ë ASCOT–LLA) ÛÙ· 903 ÂÂÈÛfi‰È· Î·È fi¯È ÛÙ· 1.150 Ô˘ ›¯·Ó ۯ‰ȷÛı› ÏfiÁˆ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ ı·Ó¿ÙˆÓ ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÙÂÓÔÏfiÏ˘. ™ÙÔ
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Ù¤ÏÔ˜ Ù˘ ÌÂϤÙ˘ Ë ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ (78%) ¤·ÈÚÓ ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰‡Ô Ê¿Ú̷η Î·È ÌfiÓÔ 15% Î·È 9% ¤·ÈÚÓ ·ÌÏԉțÓË ‹ ·ÙÂÓÔÏfiÏË Û·Ó ÌÔÓÔıÂڷ›· ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ÙÂÏÈ΋ ·Ó¿Ï˘ÛË Ù˘ ÌÂϤÙ˘ Ù· ı·Ó·ÙËÊfiÚ· Î·È ÌË ı·Ó·ÙËÊfiÚ· ÂÂÈÛfi‰È· (ÚˆÙÔÁÂÓ¤˜ ÙÂÏÈÎfi ÛËÌ›Ô) ÌÂÈÒıËÎ·Ó Î·Ù¿ 10% ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÌÏԉțÓ˘ ·ÏÏ¿ ·˘Ùfi ‰ÂÓ ‹Ù·Ó ÛËÌ·ÓÙÈο ÛÙ·ÙÈÛÙÈÎfi. ™ÙËÓ ÔÚ›· Ù˘ ÌÂϤÙ˘ ÔÈ ÂÚ¢ÓËÙ¤˜ – ÏfiÁˆ ·˘ÍË̤Ó˘ Û˘¯ÓfiÙËÙ·˜ ÂÂÌ‚¿ÛÂˆÓ ÛÙ· ÛÙÂÊ·ÓÈ·›· – ÚÔÛ¤ıÂÛ·Ó Î·È ¿ÏÏÔ ¤Ó· ÚˆÙÔÁÂÓ¤˜ ÙÂÏÈÎfi ÛËÌÂ›Ô ·˘Ùfi Ù˘ ·ӷÁÁ›ˆÛ˘ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ. ∆Ô ÙÚÔÔÔÈË̤ÓÔ ÙÂÏÈÎfi ÛËÌÂ›Ô ÌÂÈÒıËΠÛËÌ·ÓÙÈο ηٿ 14%. ∂›Û˘ ÌÂÈÒıËÎ·Ó ÛËÌ·ÓÙÈο Ë Î·Ú‰È·ÁÁÂȷ΋ Î·È ÔÏÈ΋ ıÓËÙfiÙËÙ· ηٿ 24% Î·È 11% ·ÓÙ›ÛÙÔȯ·, Î·È Ù· ı·Ó·ÙËÊfiÚ· Î·È ÌË ı·Ó·ÙËÊfiÚ· ÂÁÎÂÊ·ÏÈο ηٿ 23%. ¶·ÚÔÌÔ›ˆ˜ ¤Ó· Û˘Ó‰˘·Ṳ̂ÓÔ ÙÂÏÈÎfi ÛËÌÂ›Ô Û‡ÓËı˜ Û ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ·ÓÙÈ˘ÂÚÙ·ÛÈÎÒÓ ÂΛÓÔ ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ı·Ó¿ÙÔ˘, ÌË ı·Ó·ÙËÊfiÚÔ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ Î·È ÂÁÎÂÊ·ÏÈÎÔ‡ ÌÂÈÒıËΠÛÙËÓ ÔÌ¿‰· Ù˘ ·ÌÏԉțÓ˘ ηٿ 16%.
∆Ô fiÊÂÏÔ˜ Ê·›ÓÂÙ·È Ó· ÔÊ›ÏÂÙ·È ÛÙË ÌÂÁ·Ï‡ÙÂÚË Ì›ˆÛË Ù˘ ›ÂÛ˘ Ô˘ ÛËÌÂÈÒıËΠÛÙËÓ ÔÌ¿‰· Ù˘ ·ÌÏԉțÓ˘ Î·È ‹Ù·Ó 5,9/2,4 mmHg ÛÙÔ˘˜ 3 Ì‹Ó˜ Î·È Ì›· ̤ÛË ‰È·ÊÔÚ¿ ›ÂÛ˘ 2,7/1,9 mmHg ÛÙÔ Ù¤ÏÔ˜ Ù˘ ÌÂϤÙ˘. ∆Ô ÛËÌ·ÓÙÈÎfi fiÊÂÏÔ˜ Ô˘ ·Ú·ÙËÚ‹ıËΠÛÙÔ˘˜ ˘ÂÚÙ·ÛÈÎÔ‡˜ ·ÛıÂÓ›˜ ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÌÏԉțÓ˘ ÙÔÓ›ÛıËÎÂ Î·È Û ¿ÏÏË ÌÂϤÙË Ô˘ Û˘Ófi‰Â˘Â ÙÔ Î‡ÚÈ· ÌÂϤÙË3. ™’ ·˘Ù‹ ÙË ‰Â‡ÙÂÚË ÌÂϤÙË ÔÈ ÂÚ¢ÓËÙ¤˜ ‰ÂÓ Û˘ÌʈÓÔ‡Ó Ì ÙËÓ ÂÍ‹ÁËÛË fiÙÈ ÙÔ fiÊÂÏÔ˜ ·Ô‰›‰ÂÙ·È ÛÙË Ì›ˆÛË Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘. ÿÛˆ˜ Ë ‰È·ÊÔÚÂÙÈ΋ ·ÏÏËÏ·ÓÙ›‰Ú·ÛË Ù˘ ·ÌÏԉțÓ˘ Ì ÙË ÛÙ·Ù›ÓË Â›Ó·È ¤Ó·˜ Èı·Ófi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ Ó· ÌÔÚ› Ó· ÂÍËÁ› ¤Ó· ̤ÚÔ˜ ·fi ÙÔ fiÊÂÏÔ˜. ŒÓ· ¿ÏÏÔ ‰˘ÓËÙÈÎfi fiÊÂÏÔ˜ Ô˘ ÚԤ΢„ ÛÙË ÌÂϤÙË ASCOT–µPLA ‹Ù·Ó Ë Î·Ù¿ 30% ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÂÌÊ¿ÓÈÛ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ 2 ÛÙËÓ ÔÌ¿‰· Ù˘ ·ÌÏԉțÓ˘. ∆Ô ÂÚÒÙËÌ· ·Ó ·˘Ùfi ÔÊ›ÏÂÙ·È ÛÙÔÓ Û˘Ó‰˘·ÛÌfi ·ÌÏԉțÓ˘ ÂÚÈÓ‰ÔÚ›Ï˘ ‹ Û Âȉ›ӈÛË ·fi ÙÔÓ Û˘Ó‰˘·ÛÌfi ·ÙÂÓÔÏfiÏ˘ ‰ÈÔ˘ÚËÙÈÎÒÓ ‰ÂÓ ÌÔÚ› Ó· ··ÓÙËı›. ∆Ô ›‰ÈÔ ÂÚÒÙËÌ· ÂÍ¿ÏÏÔ˘ ›¯Â ÙÂı› Î·È ÛÙËÓ ÂÚÌËÓ›· ·ÚÔÌÔ›Ô˘ Â˘Ú‹Ì·ÙÔ˜ Ì ÙË Û‡ÁÎÚÈÛË ·ÙÂÓÔÏfiÏ˘ Î·È ÏÔÛ·ÚÙ¿Ó˘ ÛÙË ÌÂϤÙË LIFE. √ ·ÚÈıÌfi˜ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ Ú¤ÂÈ Ó· ıÂڷ¢ı› ÁÈ· ¤Ó· ¤ÙÔ˜ ÁÈ· Ó· ÚÔÏËÊı› 1 ηډȷÁÁÂÈ·Îfi Û˘Ì‚¿Ó ‹ 1 ı¿Ó·ÙÔ˜ Â›Ó·È 220 Î·È 650 ·ÓÙ›ÛÙÔȯ·. √ ·ÚÈıÌfi˜ Ê·›ÓÂÙ·È ÌÈÎÚfi˜ ÁÈ· Ù· 5 ¯ÚfiÓÈ· ·ÏÏ¿ ·Ó ηÓ›˜ Ï¿‚ÂÈ ˘fi fi„ÈÓ ÙÔ˘ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· Ì·ÎÚÔ¯ÚfiÓÈ· ıÂڷ›· ·ÔÎÙ¿ ÌÂÁ·Ï‡ÙÂÚË ·Í›·. √ ÛÙfi¯Ô˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ∞¶ ηıÔÚ›˙ÂÙ·È ·fi ÙË ·ÚÔ˘Û›· ‹ ÌË ‚Ï¿‚˘ ÛÙ· fiÚÁ·Ó· ÛÙfi¯Ô˘˜, ‰È·‚‹ÙË ‹ ¿ÏÏˆÓ Î·Ú-
∫§π¡π∫∂™ ª∂§∂∆∂™ ‰È·ÁÁÂÈ·ÎÒÓ ·Ú·ÁfiÓÙˆÓ ÎÈÓ‰‡ÓÔ˘ Î·È ÔÈ Û˘ÛÙ¿ÛÂȘ ‚·Û›˙ÔÓÙ·È Û ·ÔÙÂϤÛÌ·Ù· ÌÂÁ¿ÏˆÓ ÎÏÈÓÈÎÒÓ ÌÂÏÂÙÒÓ Î·È Û˘ÛÙ¿ÛÂˆÓ ÙˆÓ ÂÈÙÚÔÒÓ Ô‰ËÁÈÒÓ. ∆ÒÚ·, ·Ó Ë ÌÂϤÙË ASCOT ı· ·ÏÏ¿ÍÂÈ ÙȘ ηÙ¢ı˘ÓÙ‹ÚȘ Ô‰ËÁ›Â˜ Î·È ı· Û˘ÛÙ‹ÛÂÈ ·ÓÙ·ÁˆÓÈÛÙ‹ ·Û‚ÂÛÙ›Ô˘ Ì ‹ ¯ˆÚ›˜ ·ÓÙ·ÁˆÓÈÛÙ‹ ÙÔ˘ ¿ÍÔÓ· ÚÂÓ›Ó˘ - ·ÁÁÂÈÔÙ·Û›Ó˘ Û·Ó ÚÒÙË ÂÈÏÔÁ‹, ·Ú·Ì¤ÓÂÈ
¿ÁÓˆÛÙÔ. ∆· ‰ÈÔ˘ÚËÙÈο Û›ÁÔ˘Ú· ı· ·Ú·Ì›ÓÔ˘Ó Û·Ó Û˘ÌÏËڈ̷ÙÈ΋ ıÂڷ›·. ∏ ·Í›· ÙˆÓ ‚·Ó·ÛÙÔϤˆÓ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘ Â›Ó·È Î·Ï¿ ÙÂÎÌËÚȈ̤ÓË. ¢ÂÓ Ú¤ÂÈ Ó· Ì·˜ ‰È·Ê‡ÁÂÈ fiÙÈ ÔÈ ˘ÂÚÙ·ÛÈÎÔ› Ì ¤ÌÊÚ·ÁÌ· ‹ ÛÙËı¿Á¯Ë ·ÔÙÂÏÔ‡Û·Ó ÎÚÈÙ‹ÚÈ· ·ÔÎÏÂÈÛÌÔ‡ Ù˘ ÌÂϤÙ˘ ASCOT Î·È Û˘ÓÂÒ˜ Ë ÂÚÌËÓ›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ
Ú¤ÂÈ Ó· Á›ÓÂÙ·È Ì ÚÔÛÔ¯‹ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜. ∏ ·Í›· fï˜ Ù˘ ·ÙÂÓÔÏfiÏ˘ (ÛÂ Û˘Ó‰˘·ÛÌfi Ì ‰ÈÔ˘ÚËÙÈο Â›Ó·È ·fi Ù· ÈÔ Û˘¯Ó¿ Û˘ÓÙ·ÁÔÁÚ·ÊÔ‡ÌÂÓ· ·ÓÙÈ˘ÂÚÙ·ÛÈο Û¯‹Ì·Ù·) ¤¯ÂÈ ·ÌÊÈÛ‚ËÙËı› ÚfiÛÊ·Ù· 4 Î·È Ë Ù‡¯Ë Ù˘ ÌÂÙ¿ Î·È ·fi ·˘Ù‹ ÙË ÌÂϤÙË Á›ÓÂÙ·È ÚÔ‚ÏËÌ·ÙÈÎfiÙÂÚË.
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Poulter NR, Wedel H, Dahlfif B, et al. Role of blood pressure and other variables in the differential cardiovascular event rates noted in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA). Lancet 2005; 366: 907–13
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Carlberg B, Samuelsson O, Lindholm LH. Atenolol in hypertension: is it a wise choice? Lancet 2004; 364: 1684–89.
µÈ‚ÏÈÔÁÚ·Ê›· 1.
Sever PS, Dahlof B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lowerthan-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003; 361: 1149–58.
Dahlff B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atendol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005; 366: 895–906
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·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
∂ӉȷʤÚÔÓ ¶ÂÚÈÛÙ·ÙÈÎfi ∂ÈÚ‹ÓË °·˙‹, ∂ÈÛÙËÌoÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ π·ÙÚ›Ԣ §Èȉ›ˆÓ ∂˘¿ÁÁÂÏÔ˜ §˘ÌÂÚfiÔ˘ÏÔ˜, ¶·ıÔÏfiÁÔ˜, ¢È‰¿ÎÙˆÚ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ªˆ˘Û‹˜ ∂ÏÈÛ¿Ê, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜
Ó‰Ú·˜ ËÏÈΛ·˜ 44 ÂÙÒÓ ÚÔÛ‹Ïı ÛÙÔ È·ÙÚÂ›Ô ÏÈȉ›ˆÓ ÌÂ Û˘ÌÙÒÌ·Ù· ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜. ™ÙË Ê˘ÛÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËÎÂ Ë ‡·ÚÍË Ô˙ˆ‰ÒÓ Í·ÓıˆÌ¿ÙˆÓ ÛÙÔ˘˜ ·ÁÎÒÓ˜ Î·È ·Ï·ÌÈ·›ˆÓ Í·ÓıˆÌ¿ÙˆÓ (∂ÈÎfiÓ˜ 1, 2). √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: ÔÏÈ΋ ¯ÔÏËÛÙÂÚfiÏË 1.055 mg/dl, TRG 2.900 mg/dl, HDL-¯ÔÏËÛÙÂÚfiÏË 18 mg/dl Î·È ÁÏ˘Îfi˙Ë 300 mg/dl. ¢ÔÎÈÌ¿ÛÙ ÙȘ ÁÓÒÛÂȘ ÚÈÓ ‰È·‚¿ÛÂÙ ٷ Û¯fiÏÈ·.
Õ
1. H ·Ó‡ÚÂÛË ·Ï·ÌÈ·›ˆÓ Í·ÓıˆÌ¿ÙˆÓ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi ‡ÚËÌ· Ù˘ ·) ÔÈÎÔÁÂÓÔ‡˜ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜ ‚) ÔÈÎÔÁÂÓÔ‡˜ ¯˘ÏÔÌÈÎÚÔÓ·ÈÌ›·˜ Á) ‰˘Û‚ËÙ·ÏÈÔÚˆÙÂïÓ·ÈÌ›·˜ ‰) ÔÈÎÔÁÂÓÔ‡˜ Û˘Ó‰˘·Ṳ̂Ó˘ ˘ÂÚÏÈȉ·ÈÌ›·˜ 2. ™Â fiÏ· Ù· ·Ú·Î¿Ùˆ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ú·ÙËÚËıÔ‡Ó ·Ï·ÌÈ·›· Í·ÓıÒÌ·Ù· ÂÎÙfi˜ ·fi ·) ÚˆÙÔ·ı‹ ¯ÔÏÈ΋ ΛÚÚˆÛË ‚) ·Ú·ÚˆÙÂïÓ·ÈÌ›· Á) ÓÂÊÚˆÛÈÎfi Û‡Ó‰ÚÔÌÔ ‰) ˘ÂÚÏÈȉ·ÈÌ›· Ù‡Ô˘ πππ 3. ŸÏ· Ù· ·Ú·Î¿Ùˆ ‚ÔËıÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘, ÂÎÙfi˜ ·fi ·) ‰˘ÛÏÈȉ·ÈÌ›· Ì TRG/TC = 2/1 ‚) ÂÚÈÊÂÚÈ΋ ·ÁÁÂÈÔ¿ıÂÈ· Á) Í·ÓıÒÌ·Ù· ‰) Û˘ÁΤÓÙÚˆÛË ÁÏ˘Îfi˙˘ ÓËÛÙ›·˜ Â) ·˘ÍË̤ӷ ›‰· LDL ¯ÔÏËÛÙÂÚfiÏ˘
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4. °È· ÙË Ê·ÈÓÔÙ˘È΋ ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ Â›Ó·È ··Ú·›ÙËÙË ·) ÁÂÓÂÙÈ΋ Ì›ˆÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ LDL ˘Ô‰Ô¯¤ˆÓ ‚) ›ÎÙËÙË ‰È·Ù·Ú·¯‹ Ô˘ ÂËÚ¿˙ÂÈ ÙËÓ Ë·ÙÈ΋ ·Ú·ÁˆÁ‹ ÙˆÓ ÏÈÔÚˆÙÂïÓÒÓ ‹ ÙÔÓ Î·Ù·‚ÔÏÈÛÌfi ÙÔ˘˜ Á) ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ Ô‰ËÁ› Û Ì›ˆÛË Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ Ù˘ ÏÈÔÚˆÙÂïÓÈ΋˜ ÏÈ¿Û˘
‰) ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ Ô‰ËÁ› Û Ì›ˆÛË Ù˘ Ë·ÙÈ΋˜ ·Ú·ÁˆÁ‹˜ ÙˆÓ ÏÈÔÚˆÙÂïÓÒÓ 5. ŸÏ˜ ÔÈ ·Ú·Î¿Ùˆ ·ıÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜ ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ÏÈÔÚˆÙÂïÓÈÎÒÓ Î·Ù·ÏÔ›ˆÓ, ÂÎÙfi˜ ·fi ·) ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ‚) ·¯˘Û·ÚΛ· Á) ·ÏÎÔÔÏÈÛÌfi˜ ‰) ¯ÔÏfiÛÙ·ÛË 6. ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ˘ÔΛÌÂÓË ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÈ ÙË ÓfiÛÔ ·) ÔÈ ·ÛıÂÓ›˜ Â›Ó·È ÔÌÔ˙˘ÁÒÙ˜ ∂2∂2 ‚) ÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ Έ‰ÈÎÔÔÈ› ÙËÓ Ë·ÙÈ΋ ÏÈ¿ÛË Á) ÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ Έ‰ÈÎÔÔÈ› ÙËÓ LCAT ‰) ÔÈ ·ÛıÂÓ›˜ ¤¯Ô˘Ó ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ô˘ Έ‰ÈÎÔÔÈ› ÙËÓ ·ÔÏÈÔÚˆÙÂ˚ÓË ∞-IV 7. √È ·ÛıÂÓ›˜ Ì ‰˘Û‚ËÙ·ÏÈÔÚˆÙÂïÓ·ÈÌ›· ÂÌÊ·Ó›˙Ô˘Ó Û˘Ó‹ıˆ˜ ·) ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·ÁÎÚ·ٛÙȉ·˜ ‚) ȉȷ›ÙÂÚ· ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÂÚÈÊÂÚÈ΋˜ ·ÁÁÂÈÔ¿ıÂÈ·˜ Á) ȉȷ›ÙÂÚ· ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ·ÚÔ‰ÈÎÔ‡ ÈÛ¯·ÈÌÈÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ‰) ȉȷ›ÙÂÚ· ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ıÚfiÌ‚ˆÛ˘ ÙˆÓ ·ÁÁ›ˆÓ ÙÔ˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԇ˜ 8. ŸÏ· Ù· ·Ú·Î¿Ùˆ ·ÔÙÂÏÔ‡Ó ıÂڷ¢ÙÈο ̤۷ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÂÚÏÈȉ·ÈÌ›·˜ Ù‡Ô˘ πππ ÂÎÙfi˜ ·fi ·) ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÔΛÌÂÓ˘ ÓfiÛÔ˘ ‚) ‰›·ÈÙ· Á) ÊÈÌÚ¿Ù˜ ± ÛÙ·Ù›Ó˜ ‰) ¯ÔÏÂÛÙ˘Ú·Ì›ÓË
™¯fiÏÈ· ∏ ÔÈÎÔÁÂÓ‹˜ ˘ÂÚÏÈÔÚˆÙÂïÓ·ÈÌ›· Ù‡Ô˘ πππ (‰˘Û‚ËÙ·ÏÈÔÚˆÙÂïÓ·ÈÌ›·) ·ÔÙÂÏ› Ì›· ÁÂÓÂÙÈ΋ ‰È·Ù·Ú·¯‹ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ÏÈÔÚˆÙÂïÓÒÓ, Ë ÔÔ›· ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙË Û˘ÛÛÒÚ¢ÛË ÏÈÔÚˆÙÂïÓÈÎÒÓ Î·Ù·ÏÔ›ˆÓ (remnants) ÛÙÔ Ï¿ÛÌ· Î·È ÙËÓ ·Ó¿Ù˘ÍË ÚÒÈÌ˘ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘. ∏ ·ÚÈ· ÌÔÚȷ΋ ‰È·Ù·Ú·¯‹ Ù˘ ÓfiÛÔ˘ ·ÊÔÚ¿ ÙËÓ ·ÚÔ˘Û›· ÂÏ·Ùو̷ÙÈ΋˜ ˆ˜ ÚÔ˜ ÙËÓ ÈηÓfiÙËÙ· Û‡Ó‰ÂÛ˘ Ì ÙÔ˘˜ ÏÈÔÚˆÙÂïÓÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ ·ÔÏÈÔÚˆÙÂ˚Ó˘ (Apo) E (∂ÈÎfiÓ· 3). ∏ ApoE ‚Ú›ÛÎÂÙ·È Ê˘ÛÈÔÏÔÁÈο ÛÙ· ηٿÏÔÈ· ÙˆÓ ¯˘ÏÔÌÈÎÚÒÓ Î·È ÙˆÓ VLDL (IDL) Î·È Û˘Ó‰¤ÂÙ·È Ì ÙÔ˘˜ Ë·ÙÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚfiÛÏË„Ë ·˘ÙÒÓ ÙˆÓ Î·Ù·ÏÔ›ˆÓ ·fi ÙÔ ‹·Ú. À¿Ú¯Ô˘Ó ÙÚÂȘ ÈÛÔÌÔÚʤ˜ Ù˘ ApoE (∂2, ∂3, ∂4) Ô˘ ‰È·Ê¤ÚÔ˘Ó ˆ˜ ÚÔ˜ ÙËÓ ÈηÓfiÙËÙ· Û‡Ó‰ÂÛ˘ Ì ÙÔÓ ˘Ô‰Ô¯¤·. ™˘ÁÎÂÎÚÈ̤ӷ, Ë ÈÛÔÌÔÚÊ‹ ∂2 ¤¯ÂÈ ÙË ÌÈÎÚfiÙÂÚË ÈηÓfiÙËÙ· Û‡Ó‰ÂÛ˘ Ì ÙÔÓ ˘Ô‰Ô¯¤· Î·È Ë ÈÛÔÌÔÚÊ‹ ∂4 ÙË ÌÂÁ·Ï‡ÙÂÚË. ŒÙÛÈ, ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó ˘ÂÚÏÈȉ·ÈÌ›· Ù‡Ô˘ πππ Â›Ó·È ÔÌÔ˙˘ÁÒÙ˜ ˆ˜ ÚÔ˜ ÙËÓ ∂2 (∂2∂2). ∏ ·ÚÔ˘Û›· ·˘Ù‹˜ Ù˘ ÁÂÓÂÙÈ΋˜ ‰È·Ù·Ú·¯‹˜ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ÌÂȈ̤ÓË ÚfiÛÏË„Ë ÙˆÓ Î·Ù·ÏÔ›ˆÓ ÙˆÓ ¯˘ÏÔÌÈÎÚÒÓ Î·È ÙˆÓ VLDL ·fi ÙÔ ‹·Ú Î·È Û˘ÓÂÒ˜ ÙË Û˘ÛÛÒÚÂ˘Û‹ ÙÔ˘˜ ÛÙÔ Ï¿ÛÌ·. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ ÁÔÓÔÙ‡Ô˘ ∂2∂2 ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi Â›Ó·È 1/100, ÂÓÒ Ë Â›ÙˆÛË Ù˘ ˘ÂÚÏÈȉ·ÈÌ›·˜ Ù‡Ô˘ πππ ÂÎÙÈÌ¿Ù·È Û 1/10000. ∞˘Ùfi ÛËÌ·›ÓÂÈ fiÙÈ ÌfiÓÔ ÙÔ 1% ÙˆÓ ÔÌÔ˙˘ÁˆÙÒÓ ∂2∂2 ÂÎÊÚ¿˙Ô˘Ó ÎÏÈÓÈο ÙË ÓfiÛÔ. ÃÚÂÈ¿˙ÂÙ·È Ì›· ÂÈÚfiÛıÂÙË ‰È·Ù·Ú·¯‹ Ô˘ ı· ·˘Í‹ÛÂÈ ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ ÏÈÔÚˆÙÂïÓÈÎÒÓ Î·Ù·ÏÔ›ˆÓ Î·È Ë ÔÔ›· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ÂÏ·Ùو̤ÓÔ Î·Ù·‚ÔÏÈÛÌfi ÙÔ˘˜ ı· ÚÔηϤÛÂÈ ÙË Ê·ÈÓÔÙ˘È΋ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. √È ÈÔ Û˘¯Ó¤˜ ‰È·Ù·Ú·¯¤˜ Ô˘ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ÎÏÈÓÈ΋ ÂÌÊ¿ÓÈÛË Ù˘ ˘ÂÚÏÈȉ·ÈÌ›·˜ Ù‡Ô˘ πππ Â›Ó·È Ô Û·Î¯·Ú҉˘ ‰È·-
∂¡¢π∞º∂ƒ√¡ ¶∂ƒπ™∆∞∆π∫√ ‚‹Ù˘, Ë ·¯˘Û·ÚΛ·, Ô ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜, Ë ÂÌÌËÓfi·˘ÛË, Ô ·ÏÎÔÔÏÈÛÌfi˜, ηıÒ˜ Î·È ¿ÏϘ ÁÂÓÂÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ÏÈȉ›ˆÓ. ¶Ú¤ÂÈ Ó· ÂÈÛËÌ·Óı› fiÙÈ Ì›· Û¿ÓÈ· ·ÈÙ›· Û˘ÛÛÒÚ¢Û˘ ÙˆÓ ÏÈÔÚˆÙÂïÓÈÎÒÓ Î·Ù·ÏÔ›ˆÓ (Ê·ÈÓfiÙ˘Ô˜ Ù‡Ô˘ πππ) Â›Ó·È Ë ·Ó¿ÚÎÂÈ· Ù˘ Ë·ÙÈ΋˜ ÏÈ¿Û˘ (¤Ó˙˘ÌÔ ··Ú·›ÙËÙÔ ÁÈ· ÙË ÌÂÙ·ÙÚÔ‹ ÙˆÓ Î·Ù·ÏÔ›ˆÓ ÙˆÓ VLDL Û LDL). ™Â ·˘Ù‹ ÙËÓ ÂÚ›ÙˆÛË fï˜ Ù· ›‰· Ù˘ HDL ¯ÔÏËÛÙÂÚfiÏ˘ Â›Ó·È ·˘ÍË̤ӷ, Û ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤¯Ô˘Ó Ù˘È΋ ˘ÂÚÏÈȉ·ÈÌ›· Ù‡Ô˘ πππ, ÔÈ ÔÔ›ÔÈ ¤¯Ô˘Ó Û˘¯Ó¿ ÌÂȈ̤ӷ ›‰· HDL ¯ÔÏËÛÙÂÚfiÏ˘. ∏ ÓfiÛÔ˜ ÂΉËÏÒÓÂÙ·È ÎÏÈÓÈο ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 20 ÂÙÒÓ Î·È ÓˆÚ›ÙÂÚ· ÛÙÔ˘˜ ¿Ó‰Ú˜ Û ۇÁÎÚÈÛË Ì ÙȘ Á˘Ó·›Î˜, ÛÙȘ Ôԛ˜ Ë ÓfiÛÔ˜ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛı› ÌÂÙ¿ ÙËÓ ÂÌÌËÓfi·˘ÛË. ∆Ô ¯·Ú·ÎÙËÚÈÛÙÈÎfi ÎÏÈÓÈÎfi ÁÓÒÚÈÛÌ· Ù˘ ÓfiÛÔ˘ Â›Ó·È Ù· Ù·ÈÓÈÔÂȉ‹ Í·ÓıÒÌ·Ù· ÙˆÓ ·Ï·ÌÒÓ (striata palmaris) Î·È Ù· Ô˙Ò‰Ë Í·ÓıÒÌ·Ù· (tuberous). ∆· ·Ï·ÌÈ·›· Í·ÓıÒÌ·Ù· ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û ÎÈÙÚÈÓˆfi ‹ ÔÚÙÔηÏfi¯ÚÔÔ ·Ô¯ÚˆÌ·ÙÈÛÌfi ÙˆÓ Ù˘¯ÒÓ ÙˆÓ ·Ï·ÌÒÓ Î·È ÙˆÓ ‰·ÎÙ‡ÏˆÓ ÙˆÓ ¯ÂÚÈÒÓ Î·È ÌÔÚ› Ó· Â›Ó·È Â›Â‰· ‹ ˘ÂÁÂṲ́ӷ (∂ÈÎfiÓ· 1). ∆· Ô˙Ò‰Ë Í·ÓıÒÌ·Ù· Â›Ó·È ÌÂÁ¿Ï· (>2 ÂÎ) ‰ÂÚÌ·ÙÈο Í·ÓıÒÌ·Ù·, Ô˘ Û˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ˘˜ ·ÁÎÒÓ˜ Î·È Ù· ÁfiÓ·Ù· ‹ Û·ÓÈfiÙÂÚ· ÛÙȘ ı¤ÛÂȘ ›ÂÛ˘ ÙˆÓ Ô‰ÈÒÓ ·fi Ù· ˘Ô‰‹Ì·Ù·. ¶·ÚfiÌÔÈ· Í·ÓıÒÌ·Ù· ÌÔÚ› Ó· ÂÌÊ·ÓÈÛıÔ‡Ó Î·È Û ÔÚÈṲ̂Ó˜ ‰Â˘ÙÂÚÔ·ı›˜ ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙˆÓ ÏÈȉ›ˆÓ, fiˆ˜ Û ·ÔÊÚ·ÎÙÈ΋ Ë·ÙÈ΋ ÓfiÛÔ, ·Ú·ÚˆÙÂïÓ·È̛˜ Î·È ÛÂ Û˘ÛÙËÌ·ÙÈÎfi ÂÚ˘ıËÌ·ÙÒ‰Ë Ï‡ÎÔ. √È ·ÛıÂÓ›˜ Ì ˘ÂÚÏÈȉ·ÈÌ›· Ù‡Ô˘ πππ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ÚÒÈÌ˘ ·ıËڈ̷ÙÈ΋˜ ÓfiÛÔ˘ ÂÍ·ÈÙ›·˜ Ù˘ ·ÚÔ˘Û›·˜ ÙˆÓ ÂÍ·ÈÚÂÙÈο ·ıËÚÔÁfiÓˆÓ ‚-VLDL (·Ú¿ Ù· Û¯ÂÙÈο ¯·ÌËÏ¿ ›‰· Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘). ∏ ·ıËڈ̿وÛË Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ ‰ÂÓ ·ÊÔÚ¿ ÌfiÓÔ Ù· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›·, ·ÏÏ¿ ΢ڛˆ˜ Ù· ÂÚÈÊÂÚÈο ·ÁÁ›·, fiˆ˜ ÙȘ ¤Ûˆ ηڈٛ‰Â˜, ÙËÓ ÎÔÈÏȷ΋ ·ÔÚÙ‹ Î·È ÎÏ¿‰Ô˘˜ Ù˘. ŒÙÛÈ, Ë ÓfiÛÔ˜ Û˘¯Ó¿ ÂÈϤÎÂÙ·È Ì ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘, ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È·, ‰È·ÏÂ›Ô˘Û· ¯ˆÏfiÙËÙ· Î·È Á¿ÁÁÚ·ÈÓ· ÙˆÓ Î¿ÙˆÓ ¿ÎÚˆÓ. √ È·ÙÚfi˜ Ú¤ÂÈ Ó· ˘Ô„È·Ûı› ÙË ÓfiÛÔ Û ·ÛıÂÓ›˜ Ì ˘ÂÚÏÈÈ-
‰·ÈÌ›· Ô˘ ÂÌÊ·Ó›˙Ô˘Ó Ù· ¯·Ú·ÎÙËÚÈÛÙÈο Í·ÓıÒÌ·Ù·. ∂›Û˘, Ë ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ ˘Ô‚ÔËıÂ›Ù·È fiÙ·Ó ˘¿Ú¯Ô˘Ó ·˘ÍË̤ӷ ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Î·È ¯ÔÏËÛÙÂÚfiÏ˘ ÛÙÔ Ï¿ÛÌ· Î·È Ì¿ÏÈÛÙ· fiÙ·Ó ÔÈ ·fiÏ˘Ù˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙÔ˘˜ Û mmol/l Â›Ó·È ›Û˜ Î·È Û mg/dl Ë Û˘ÁΤÓÙÚˆÛË ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ Â›Ó·È ‰ÈÏ¿ÛÈ· ·fi ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘. ™ÙËÓ ËÏÂÎÙÚÔÊfiÚËÛË ÙˆÓ ÏÈÔÚˆÙÂïÓÒÓ Û ·Á·Úfi˙Ë ·Ú·ÙËÚÂ›Ù·È Ì›· ¢Ú›· ÚÔ-‚ ˙ÒÓË (‚-VLDL) Ô˘ ·ÓÙÈÛÙÔȯ› ÛÙȘ ÏÔ‡ÛȘ Û ÙÚÈÁÏ˘ÎÂÚ›‰È· Î·È ¯ÔÏËÛÙÂÚfiÏË ·ıÔÏÔÁÈΤ˜ ÏÈÔÚˆÙÂ˚Ó˜. H ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒÓÂÙ·È Ì ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ ÏfiÁÔ˘ Ù˘ VLDL ¯ÔÏËÛÙÂÚfiÏ˘ ÚÔ˜ Ù· ÔÏÈο ÙÚÈÁÏ˘ÎÂÚ›‰È· ÙÔ˘ ÔÚÔ‡: ¤Ó·˜ ÏfiÁÔ˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi 0,3 (fiÙ·Ó ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ ÏÈȉ›ˆÓ ÂÎÊÚ¿˙ÔÓÙ·È Û mg/dl) ‹ 0,68 (fiÙ·Ó ÔÈ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ ÏÈȉ›ˆÓ ÂÎÊÚ¿˙ÔÓÙ·È Û mmol/l) Â›Ó·È ·ıÔÁÓˆÌÈÎfi˜ Ù˘ ÓfiÛÔ˘. ∆¤ÏÔ˜, ÛÙËÓ ÈÛÔËÏÂÎÙÚÈ΋ ÂÛÙ›·ÛË ÙˆÓ ÚˆÙÂïÓÒÓ ÙˆÓ VLDL ‰È·ÈÛÙÒÓÂÙ·È Ô Ê·ÈÓfiÙ˘Ô˜ ∂2∂2 (∂ÈÎfiÓ· 4). ŸÛÔÓ ·ÊÔÚ¿ ÙË ıÂڷ¢ÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ ˘ÂÚÏÈȉ·ÈÌ›·˜ Ù‡Ô˘ πππ, ¤¯ÂÈ È‰È·›ÙÂÚË ÛËÌ·Û›· Ë ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ˘ÔΛÌÂÓˆÓ ‰È·Ù·Ú·¯ÒÓ: ·ÒÏÂÈ· ‚¿ÚÔ˘˜ Û ·¯‡Û·ÚÎÔ˘˜ ·ÛıÂÓ›˜, Ú‡ıÌÈÛË ÙÔ˘ ۷ί¿ÚÔ˘ Û ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Î·È ¯ÔÚ‹ÁËÛË ı˘ÚÔ͛Ӣ Û ·ÛıÂÓ›˜ Ì ˘Ôı˘ÚÂÔÂȉÈÛÌfi. ™˘¯Ó¿ Â›Ó·È ·Ó·Áη›· Ë ¯ÔÚ‹ÁËÛË ˘ÔÏÈȉ·ÈÌÈ΋˜ ·ÁˆÁ‹˜. ∆· Ê¿Ú̷η ÚÒÙ˘ ÂÈÏÔÁ‹˜ Â›Ó·È ÔÈ ÊÈÌÚ¿Ù˜, Ô˘ ÂÎÙfi˜ ·fi ÙË ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÏÈȉ·ÈÌÈÎÔ‡ ÚÔÊ›Ï, Û˘¯Ó¿ Û˘Ì‚¿ÏÏÔ˘Ó Î·È ÛÙËÓ ˘ÔÛÙÚÔÊ‹ ÙˆÓ Í·ÓıˆÌ¿ÙˆÓ. ∂Ó·ÏÏ·ÎÙÈο Ê¿Ú̷η ·ÔÙÂÏÔ‡Ó ÔÈ ÛÙ·Ù›Ó˜ Î·È ÙÔ ÓÈÎÔÙÈÓÈÎfi Ô͇, ÂÓÒ Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ··ÈÙËı› Ë ¯ÔÚ‹ÁËÛË Û˘Ó‰˘·ÛÌÔ‡ ˘ÔÏÈȉ·ÈÌÈÎÒÓ Ê·Ú̿ΈÓ.
∂ÈÎfiÓ· 1. √˙Ò‰Ë Í·ÓıÒÌ·Ù· ÛÙÔ˘˜ ·ÁÎÒÓ˜ Û ·ÛıÂÓ‹ Ì ‰˘Û‚ËÙ·ÏÈÔÚˆÙÂïÓ·ÈÌ›· (˘ÂÚÏÈÔÚˆÙÂïÓ·ÈÌ›· Ù‡Ô˘ πππ)
∂ÈÎfiÓ· 2. ¶·Ï·ÌÈ·›· Í·ÓıÒÌ·Ù· Û ·ÛıÂÓ‹ Ì ‰˘Û‚ËÙ·ÏÈÔÚˆÙÂïÓ·ÈÌ›· (˘ÂÚÏÈÔÚˆÙÂïÓ·ÈÌ›· Ù‡Ô˘ πππ)
∂ÈÎfiÓ· 3. ™¯ËÌ·ÙÈ΋ ·ÂÈÎfiÓÈÛË Ù˘ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÛÙË ‰˘Û‚ËÙ·ÏÈÔÚˆÙÂïÓ·ÈÌ›· (˘ÂÚÏÈÔÚˆÙÂïÓ·ÈÌ›· Ù‡Ô˘ πππ)
∂ÈÎfiÓ· 4. IÛÔËÏÂÎÙÚÈ΋ ÂÛÙ›·ÛË ÙˆÓ ÚˆÙÂ˚ÓÒÓ ÙˆÓ Ôχ ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈÔÚˆÙÂ˚ÓÒÓ (apoVLDL’s)
15
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
™˘Á¯ÔÚ‹ÁËÛË ™Ù·Ù›Ó˘ Ì ∞ÛÈÚ›ÓË Î·È ¢Â˘ÙÂÚÔÁÂÓ‹˜ ¶ÚfiÏË„Ë ∂ÈÚ‹ÓË °·˙‹, ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ ÙÔ˘ π·ÙÚ›Ԣ §Èȉ›ˆÓ ªˆ¸Û‹˜ ∂ÏÈÛ¿Ê, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜
ÙÚÔÔÔ›ËÛË ÙˆÓ ÏÈȉ·ÈÌÈÎÒÓ ·Ú·Ì¤ÙÚˆÓ Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÙˆÓ ÛÙ·ÙÈÓÒÓ ¤¯ÂÈ ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÛËÌ·ÓÙÈ΋ Ì›ˆÛË Ù˘ ηډȷÁÁÂȷ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÙfiÛÔ ÛÙËÓ ÚˆÙÔÁÂÓ‹ fiÛÔ Î·È ÛÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë1-5. ∂ÈÚfiÛıÂÙ·, Ë ¯ÔÚ‹ÁËÛË ·ÛÈÚ›Ó˘ (Ê¿ÚÌ·ÎÔ Ô˘ ·Ó·ÛÙ¤ÏÏÂÈ ÙË Û˘ÁÎfiÏÏËÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ) Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ô‰ËÁ› ›Û˘ Û Ì›ˆÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘6-7. ªÂϤÙ˜ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÚfiÏ˄˘ ¤‰ÂÈÍ·Ó fiÙÈ Ë ·ÓÙÈ·ıËÚÔÁfiÓÔ˜ ‰Ú¿ÛË ÙˆÓ ÛÙ·ÙÈÓÒÓ ·Ú·ÙËÚÂ›Ù·È Î·Ù¿ ηÓfiÓ· ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜2-4,8. ∞ÓÙ›ıÂÙ·, Ë ·ÓÙÈ·ÈÌÔÂÙ·Ïȷ΋ ‰Ú¿ÛË Ù˘ ·ÛÈÚ›Ó˘ Â›Ó·È ¿ÌÂÛË6-8. ∆· ·Ú·¿Óˆ ‰Â‰Ô̤ӷ Ô‰‹ÁËÛ·Ó ÛÙËÓ ˘fiıÂÛË fiÙÈ Ë Û˘Á¯ÔÚ‹ÁËÛË ÌÈ·˜ ÛÙ·Ù›Ó˘ Ì ·ÛÈÚ›ÓË ı· ¤¯ÂÈ – ÙÔ˘Ï¿¯ÈÛÙÔÓ – ·ıÚÔÈÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ· fiÛÔÓ ·ÊÔÚ¿ ÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘8. ¶Ú¿ÁÌ·ÙÈ, ÔÈ ÚfiÛÊ·Ù˜ Ô‰ËÁ›Â˜ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘ÂÚ¯ÔÏËÛÙÂÚÔÏ·ÈÌ›·˜ (NCEP ATPIII, National Cholesterol Education Program Adult Treatment Panel III) ˘Ô‰ÂÈÎÓ‡Ô˘Ó ÙË Û˘Á¯ÔÚ‹ÁËÛË ÛÙ·ÙÈÓÒÓ Î·È ·ÛÈÚ›Ó˘ Û ·ÛıÂÓ›˜ Ì ÁÓˆÛÙ‹ ηډȷÁÁÂȷ΋ ÓfiÛÔ 9-11. ¶·ÚfiÏ· ·˘Ù¿ Ë Û˘Á¯ÔÚ‹ÁËÛË ÛÙ·ÙÈÓÒÓ Ì ·ÛÈÚ›ÓË Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È ·ÎfiÌË È‰È·›ÙÂÚ· ‰È·‰Â‰Ô̤ÓË 12,13. ¢Â‰Ô̤ÓÔ˘ fiÙÈ Ù˘¯·ÈÔÔÈË̤Ó˜ ‰ÈϤ˜-Ù˘ÊϤ˜ ÌÂϤÙ˜ Û˘Á¯ÔÚ‹ÁËÛ˘ ÛÙ·ÙÈÓÒÓ Ì ·ÛÈÚ›ÓË ‰ÂÓ Â›Ó·È ‰˘Ó·Ùfi Ó· Ú·ÁÌ·ÙÔÔÈËıÔ‡Ó ÁÈ· ËıÈÎÔ‡˜ ÏfiÁÔ˘˜, ÔÈ ÂӉ›ÍÂȘ ÁÈ· ÙËÓ ·ÛÊ¿ÏÂÈ· Î·È ÙËÓ ˘ÂÚÔ¯‹ Ù˘ Û˘Á¯ÔÚ‹ÁËÛ‹˜
∏
16
ÙÔ˘˜ - ¤Ó·ÓÙÈ ÙÔ˘ οı ·Ú¿ÁÔÓÙ· ¯ˆÚÈÛÙ¿ - fiÛÔÓ ·ÊÔÚ¿ ÙË Ì›ˆÛË ÙÔ˘ ηډȷÁÁÂÈ·ÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÚÔ·ÙÔ˘Ó ·fi ÌÂÙ··Ó·Ï‡ÛÂȘ ‹ ·Ó·Ï‡ÛÂȘ ˘ÔÔÌ¿‰ˆÓ ÌÂÏÂÙÒÓ Ô˘ ¤¯Ô˘Ó ‹‰Ë ‰ËÌÔÛÈ¢ı›14. ™˘ÁÎÂÎÚÈ̤ӷ, ‰‡Ô ÌÂÁ¿Ï˜ Ù˘¯·ÈÔÔÈË̤Ó˜ ÌÂϤÙ˜ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÚfiÏ˄˘ ÛÙȘ Ôԛ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠڷ‚·ÛÙ·Ù›ÓË Â›Ó·È Ë LIPID (Long-term Intervention with Pravastatin in Ischemic Disease study) Î·È Ë CARE (the Cholesterol and Recurrent Events trial)2,3. ™ÙË ÌÂϤÙË LIPID Û˘ÌÌÂÙ›¯·Ó ÂÚ›Ô˘ 9000 ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ‹ ·ÛÙ·ıÔ‡˜ ÛÙËı¿Á¯Ë˜, ÔÈ ÔÔ›ÔÈ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û 40
mg Ú·‚·ÛÙ·Ù›Ó˘ ‹ Û ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ. ∫·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘ ÙÔ 83% ÙˆÓ ·ÛıÂÓÒÓ ¤·ÈÚÓ ·ÛÈÚ›ÓË. ™ÙË ÌÂϤÙË CARE Û˘ÌÌÂÙ›¯·Ó ÂÚ›Ô˘ 4.200 ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, ÔÈ ÔÔ›ÔÈ Â›Û˘ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û 40 mg Ú·‚·ÛÙ·Ù›Ó˘ ‹ Û ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ. ∫·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘ ÙÔ 84% ÙˆÓ ·ÛıÂÓÒÓ ¤·ÈÚÓ ·ÛÈÚ›ÓË. ∂ÈÚfiÛıÂÙ·, ÙÚÂȘ ÌÈÎÚfiÙÂÚ˜ ·ÁÁÂÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜ ‰Â˘ÙÂÚÔÁÂÓÔ‡˜ ÚfiÏ˄˘ ÛÙȘ Ôԛ˜ ›Û˘ ¯ÔÚËÁ‹ıËΠڷ‚·ÛÙ·Ù›ÓË Â›Ó·È Ë REGRESS (Regression Growth Evaluation Statin Study, 885 ·ÛıÂÓ›˜), Ë PLAC-I (Pravastatin Limitation of Atherosclero-
¶›Ó·Î·˜: ªÂ›ˆÛË ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ ÛÙȘ ÌÂϤÙ˜ LIPID, CARE Î·È Û ·ÁÁÂÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜ ªÂ›ˆÛË ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ (ÙÈÌ‹ p) ∞ÁˆÁ‹
£·Ó·ÙËÊfiÚÔ ‹ ÌË √∂ªÅ
πÛ¯·ÈÌÈÎfi ∞∂∂Ç
™‡ÓıÂÙÔ Î·Ù·ÏËÎÙÈÎfi ÛËÌ›ÔÑ
28% (.01)
25.9% (.16)
14.1% (.049)
34.7% (<.001)
29.7% (.008)
23.9% (<.001)
Prava+ASA vs Prava alone (CARE)
17.6% (.27)
51.3% (.02)
22.5% (.03)
Prava+ASA vs ASA alone (CARE)
20.6% (.02)
28.9% (.13)
23.6% (<.001)
Prava+ASA vs Prava alone (∞ÁÁÂÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜)
64.5% (.04)
-81.8% (.63)
-14.5%(.52)
Prava+ASA vs ASA alone (∞ÁÁÂÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜)
75.2% (.002)
-7.9% (.94)
29.4% (.04)
Prava+ASA vs Prava alone (LIPID) Prava+ASA vs ASA alone (LIPID)
Å: √͇ ŒÌÊÚ·ÁÌ· ÙÔ˘ ª˘Ôηډ›Ô˘ Ç: ∞ÁÁÂÈ·Îfi ∂ÁÎÂÊ·ÏÈÎfi ∂ÂÈÛfi‰ÈÔ Ñ: ¶ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘ÓÔÏÈο ÙÔ˘˜ ηډȷÁÁÂÈ·ÎÔ‡˜ ı·Ó¿ÙÔ˘˜, Ù· ÌË ı·Ó·ÙËÊfiÚ· ÂÌÊÚ¿ÁÌ·Ù· ÙÔ˘ Ì˘Ôηډ›Ô˘, Ù· ·ÁÁÂȷο ÂÁÎÂÊ·ÏÈο ÂÂÈÛfi‰È· ÈÛ¯·ÈÌÈÎÔ‡ Ù‡Ô˘, ηıÒ˜ Î·È ÙȘ ‰È·‰ÂÚÌÈΤ˜ ·ÁÁÂÈÔÏ·ÛÙÈΤ˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ Î·È ÙȘ ÂÂÌ‚¿ÛÂȘ ÛÙÂÊ·ÓÈ·›·˜ ·Ú·Î¿Ì„˘ Prava: ¶Ú·‚·ÛÙ·Ù›ÓË, ASA: ∞ÛÈÚ›ÓË, LIPID: Long-term Intervention With Pravastatin in Ischaemic Stroke, CARE: Cholesterol and Recurrent Events, ∞ÁÁÂÈÔÁÚ·ÊÈΤ˜ ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ ÌÂϤÙ˜ REGRESS, PLAC-I Î·È PLAC-II.
£∂ƒ∞¶∂π∞ – º∞ƒª∞∫∞ sis in the Carotid Arteries trial, 408 ·ÛıÂÓ›˜) Î·È Ë PLAC-II (Pravastatin, Lipids and Atherosclerosis in the Carotid Arteries trial, 151 ·ÛıÂÓ›˜)15-17. ∫·È Û ·˘Ù¤˜ ÙȘ ÌÂϤÙ˜ ÔÈ ·ÛıÂÓ›˜ Ù˘¯·ÈÔÔÈ‹ıËÎ·Ó Û 40 mg Ú·‚·ÛÙ·Ù›Ó˘ ‹ Û ÂÈÎÔÓÈÎfi Ê¿ÚÌ·ÎÔ Î·È Ù· ÔÛÔÛÙ¿ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ¤·ÈÚÓ·Ó ·ÛÈÚ›ÓË Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÌÂϤÙ˘ ‹Ù·Ó 54% ÛÙË REGRESS, 68% ÛÙËÓ PLAC-I Î·È 43% ÛÙËÓ PLAC-II. ª›· ÚfiÛÊ·ÙË ÌÂÙ·-·Ó¿Ï˘ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ·˘ÙÒÓ ÙˆÓ ÌÂÏÂÙÒÓ ¤‰ÂÈÍ ÛËÌ·ÓÙÈ΋ ˘ÂÚÔ¯‹ ÙÔ˘ Û˘Ó‰˘·ÛÌÔ‡ ·ÛÈÚ›Ó˘ - Ú·‚·ÛÙ·Ù›Ó˘ fiÛÔÓ ·ÊÔÚ¿ ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂȷ΋˜ ÓfiÛÔ˘ (¶›Ó·Î·˜)8. ™˘-
ÁÎÂÎÚÈ̤ӷ, ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙÔ˘ Û¯ÂÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ı·Ó·ÙËÊfiÚÔ˘ ‹ ÌË ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘ ηٿ 31% Û ·ÛıÂÓ›˜ Ô˘ ¤·ÈÚÓ·Ó Û˘Ó‰˘·ÛÌfi ·ÛÈÚ›Ó˘ Ì ڷ‚·ÛÙ·Ù›ÓË Û ۇÁÎÚÈÛË Ì ٷ ¿ÙÔÌ· Ô˘ ¤·ÈÚÓ·Ó ÌfiÓÔ ·ÛÈÚ›ÓË Î·È Î·Ù¿ 26% Û ۇÁÎÚÈÛË Ì ÂΛӷ Ù· ¿ÙÔÌ· Ô˘ ¤·ÈÚÓ·Ó ÌfiÓÔ Ú·‚·ÛÙ·Ù›ÓË. ∂ÈϤÔÓ, ·Ú·ÙËÚ‹ıËΠ̛ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ÈÛ¯·ÈÌÈÎÒÓ ·ÁÁÂÈ·ÎÒÓ ÂÁÎÂÊ·ÏÈÎÒÓ ÂÂÈÛÔ‰›ˆÓ ηٿ 29% Î·È 31% ·ÓÙ›ÛÙÔȯ·. ¶Ú¤ÂÈ Ó· ÂÈÛËÌ·Óı› fiÙÈ Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ÂÌÊ¿ÓÈÛ˘ ηډȷÁÁÂÈ·ÎÔ‡ ı·Ó¿ÙÔ˘, ÌË ı·Ó·ÙËÊfiÚÔ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, ÈÛ¯·ÈÌÈ-
ÎÔ‡ ·ÁÁÂÈ·ÎÔ‡ ÂÁÎÂÊ·ÏÈÎÔ‡ ÂÂÈÛÔ‰›Ô˘ ‹ Ú·ÁÌ·ÙÔÔ›ËÛ˘ ÛÙÂÊ·ÓÈ·›·˜ ·Ú¿Î·Ì„˘ ‹ ‰È·‰ÂÚÌÈ΋˜ ·ÁÁÂÈÔÏ·ÛÙÈ΋˜ ÌÂÈÒıËΠηٿ 24% ÛÙËÓ ÔÌ¿‰· Ô˘ ¤·ÈÚÓÂ Û˘Ó‰˘·Ṳ̂ÓË ·ÁˆÁ‹ Û ۇÁÎÚÈÛË Ì ÂΛӷ Ù· ¿ÙÔÌ· Ô˘ ¤·ÈÚÓ·Ó ÌfiÓÔ ·ÛÈÚ›ÓË Î·È Î·Ù¿ 13% Û ۇÁÎÚÈÛË Ì ٷ ¿ÙÔÌ· Ô˘ ¤·ÈÚÓ·Ó ÌfiÓÔ Ú·‚·ÛÙ·Ù›ÓË8. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Û˘Á¯ÔÚ‹ÁËÛË ÛÙ·ÙÈÓÒÓ Ì ·ÛÈÚ›ÓË Û ·ÛıÂÓ›˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ ·Ó·Ì¤ÓÂÙ·È Ó· Ô‰ËÁ‹ÛÂÈ Û ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙˆÓ Î·Ú‰È·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ.
and stroke in high-risk patients: Antithrombotic Trialists’ Collaboration (ATT) [published erratum appears in BMJ 2002;324:141]. BMJ 2002;324:71-86
of cardiovascular disease. MedGen Med (serial online). November 22, 1999; e1. Available at:http://www. medscape.com
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13. Califf RM, Delong ER, Ostbye T et al. Underuse of aspirin in a referral population with documented coronary artery disease. Am J Cardiol 2002;89:653-661
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Shepherd J, Cobbe M, Ford I et al, for the WOSCOPS study group. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995;333:1301-1307
2.
The LIPID study group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998; 339:1349-1357
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Sacks F, Pfeiffer M, Moye L et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335:1001-1009 The 4S study group. Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin survival study. Lancet 1994;344:1383-1389 The HPS study group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20536 high-risk individuals. Lancet 2002;360:7-22
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Executive summary of the Third Report of the National Cholesterol Educational Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285: 2486-2497
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Hennekens CH, Buring JE, Sandercock P et al. Aspirin and other antiplatelet agents in the secondary and primary prevention of cardiovascular disease. Circulation 1989;80:749-756
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Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction
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14. Wascher TC. Long-term statin safety and efficacy in secondary prevention: can combination therapy improve outcomes? Atherosclerosis 2003;4(suppl): 11-16 15. Jukema W, Bruschke AVG, van Boven AJ et al. Effects of lipid lowering by pravastatin on progression and regression of coronary artery disease in symptomatic men with normal to moderately elevateed serum cholesterol levels: the Regression Growth Evaluation Statin Study (REGRESS). Circulation 1995;91: 2528-2540 16. Pitt B, Mancini GB, Ellis SG et al. Pravastatin Limitation of Atherosclerosis in the the Coronary Arteries (PLAC-I): reduction in atherosclerosis progression and clinical events. J Am Coll Cardiol 1995;26: 1133-1139 17. Crouse JR, Byington RP, Bond MG et al. Pravastatin, Lipids and Atherosclerosis in the Carotid Arteries (PLAC-II). Am J Cardiol 1995;75:455-459
17
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
ÃÔÚ‹ÁËÛË ∞ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙË ¢Â˘ÙÂÚÔÁÂÓ‹ ¶ÚfiÏË„Ë Ù˘ πÛ¯·ÈÌÈ΋˜ ∫·Ú‰È·Î‹˜ ¡fiÛÔ˘ ª. ∫ˆÛÙ·¿ÓÔ˜, ∂ÈÛÙËÌÔÓÈÎfi˜ ™˘ÓÂÚÁ¿Ù˘ ÙÔ˘ π·ÙÚ›Ԣ §Èȉ›ˆÓ ª. ∂ÏÈÛ¿Ê, ∫·ıËÁËÙ‹˜ ¶·ıÔÏÔÁ›·˜ π·ÙÚÈ΋˜ ™¯ÔÏ‹˜ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ
ÈÛ¯·ÈÌÈ΋ ηډȷ΋ ÓfiÛÔ˜ ·ÔÙÂÏ› ÙË ÛËÌ·ÓÙÈÎfiÙÂÚË ·ÈÙ›· ıÓËÙfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ÎÔÈӈӛ˜1. ∏ Û‡Á¯ÚÔÓË ¤Ú¢ӷ ¤¯ÂÈ ·Ô‰Â›ÍÂÈ fiÙÈ Ë ·ıËÚÔÛÎÏ‹ÚˆÛË Â›Ó·È Ì›· ÊÏÂÁÌÔÓ҉˘ ‰È·‰Èηۛ· ÛÙËÓ ÔÔ›· Û˘ÌÌÂÙ¤¯Ô˘Ó Î·È Î‡ÙÙ·Ú· ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, fiˆ˜ Ù· Ì·ÎÚÔÊ¿Á· Î·È Ù· ∆-ÏÂÌÊÔ·ÙÙ·Ú·2,3. ∏ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ¯ÚÔÓ›ˆÓ ‚Ú·‰Â›·˜ ÂͤÏÈ͢ ÏÔÈÌÒÍÂˆÓ Î·È ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·fi ÙÔÓ Rudolf Ludwig Karl Virchow4, ÂÓÒ ÙÔ ¯Ï·Ì‡‰ÈÔ Ù˘ Ó¢ÌÔÓ›·˜ ¤¯ÂÈ ·Ó·ÁÓˆÚÈÛı› ˆ˜ ÙÔ ‚·ÎÙËÚ›‰ÈÔ Ô˘ Û˘Û¯ÂÙ›˙ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Ì ÙËÓ ÈÛ¯·ÈÌÈ΋ ηډȷ΋ ÓfiÛÔ. ¶Ú¿ÁÌ·ÙÈ, ¤¯ÂÈ ·Ô‰Âȯı› Ë ÈηÓfiÙËÙ· ÙÔ˘ ¯Ï·Ì˘‰›Ô˘ Ù˘ Ó¢ÌÔÓ›·˜ Ó· ÚÔÛ‚¿ÏÂÈ Ù· Ì·ÎÚÔÊ¿Á·, ÙȘ Ï›˜ Ì˘˚Τ˜ ›Ó˜ Î·È Ù· ÂÓ‰ÔıËÏȷο ·ÙÙ·Ú· ÙˆÓ ·ÁÁ›ˆÓ5 , ÂÓÒ ·Ú¿ÏÏËÏ· ¤¯ÂÈ ÙÂÎÌËÚȈı› Ë Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙˆÓ ˘„ËÏÒÓ Ù›ÙÏˆÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙÔ˘ ¯Ï·Ì˘‰›Ô˘ Ù˘ Ó¢ÌÔÓ›·˜ Î·È Ù˘ ÂÌÊ¿ÓÈÛ˘ ÔͤˆÓ ÂÌÊÚ·ÁÌ¿ÙˆÓ ÙÔ˘ Ì˘Ôηډ›Ô˘6. ∂ÈÚfiÛıÂÙ·, ÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ‚·ÎÙËÚ›‰ÈÔ ·ÓȯÓ‡ıËΠ۠·Ú·Û΢¿ÛÌ·Ù· ·ıËÚÔÛÎÏËÚˆÙÈÎÒÓ ‚Ï·‚ÒÓ7,8, ÂÓÒ Ô ÂÓÔÊı·ÏÌÈÛÌfi˜ ÙÔ˘ ¯Ï·Ì˘‰›Ô˘ Ù˘ Ó¢ÌÔÓ›·˜ Û ÎÔ˘Ó¤ÏÈ· Ô‰‹ÁËÛ Û ̛· ÂÈÙ¿¯˘ÓÛË Ù˘ ·ıËÚÔÛÎÏ‹ÚˆÛ˘ ÛÙ· ÛÙÂÊ·ÓÈ·›· ·ÁÁ›· ÙˆÓ ÎÔ˘ÓÂÏÈÒÓ, ÁÂÁÔÓfi˜ ÙÔ ÔÔ›Ô ÌÔÚÔ‡Û ӷ ÚÔÏËÊı› Ì ÙË ¯ÔÚ‹ÁËÛË ·˙ÈıÚÔÌ˘Î›Ó˘9. ™‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¿ ·ÓÙÈ‚ÈÔÙÈο ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·fi ÙÔ ¯Ï·Ì‡‰ÈÔ Ù˘ Ó¢ÌÔÓ›·˜. øÛÙfiÛÔ, Ë Â›‰Ú·ÛË Ù˘ ¯ÔÚ‹ÁËÛ‹˜ ÙÔ˘˜ ÛÙËÓ ÂͤÏÈÍË Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È Î·Ï¿ ÁÓˆÛÙ‹. ∆˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ Ô˘ ۯ‰ȿÛıËÎ·Ó ÁÈ· Ó· ÌÂÏÂÙ‹ÛÔ˘Ó ÙËÓ Â›-
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18
‰Ú·ÛË ·˘Ù‹ ¤‰ÂÈÍ·Ó ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ™Ùfi¯Ô˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂÙ·-·Ó¿Ï˘Û˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘. ∞ÚÎÂÙ¤˜ Û˘Á¯ÚÔÓÈΤ˜ ÌÂϤÙ˜ Î·È ÌÂϤÙ˜ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ (case-control)10,11,12,13,14 ¤¯Ô˘Ó Ú·ÁÌ·ÙÔÔÈËı› ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘. øÛÙfiÛÔ, Ù· ·ÓÙÈÎÚÔ˘fiÌÂÓ· ·ÔÙÂϤÛÌ·Ù· Î·È Ù· ÌÂıÔ‰ÔÏÔÁÈο ÛÊ¿ÏÌ·Ù¿ ÙÔ˘˜, ¤ÛÙÚ„·Ó ÙÔ ÂӉȷʤÚÔÓ ÚÔ˜ ÙȘ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ ÔÈ Ôԛ˜ ÂÈÚfiÛıÂÙ· ÌÔÚÔ‡Û·Ó Ó· ·ÍÈÔÏÔÁ‹ÛÔ˘Ó Î·È ÙËÓ Â›‰Ú·ÛË ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ‰Â›ÎÙ˜ ÊÏÂÁÌÔÓ‹˜, fiˆ˜ Ë C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË, ÙÔ ÈÓˆ‰ÔÁfiÓÔ Î·È Ë ÈÓÙÂÚÏ¢ΛÓË-6. ŒÙÛÈ, Ë ·ÚÔ‡Û· ÌÂÙ·-·Ó¿Ï˘ÛË ÂÚÈÏ·Ì‚¿ÓÂÈ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ Ô˘ ¤ÁÈÓ·Ó Ì ÙË Û˘ÌÌÂÙÔ¯‹ ·ÛıÂÓÒÓ Ì ÁÓˆÛÙ‹ ÈÛ¯·ÈÌÈ΋ ηډȷ΋ ÓfiÛÔ Î·È ÛÙȘ Ôԛ˜ ·ÍÈÔÏÔÁ‹ıËÎÂ Ë Â›‰Ú·ÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ. ∏ ‚È‚ÏÈÔÁÚ·ÊÈ΋ ¤Ú¢ӷ Ú·ÁÌ·ÙÔÔÈ‹ıËΠ‰È·Ì¤ÛÔ˘ Ù˘ ‡Ï˘ ÙÔ˘ MEDLINE Î·È Û˘ÌÂÚȤϷ‚ ÌÂϤÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Î·Ù¿ ÙÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·fi ÙÔ 1966 ¤ˆ˜ ÙÔ 2003 Ì ÛÙfi¯Ô ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘ Î·È ÔÈ Ôԛ˜ ‰ËÌÔÛȇıËÎ·Ó ÛÙËÓ ·ÁÁÏÈ΋ ÁÏÒÛÛ·. ∞·Ú·›ÙËÙ· ÎÚÈÙ‹ÚÈ· ¤ÓÙ·Í˘ ÙˆÓ Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÎÏÈÓÈÎÒÓ ‰ÔÎÈÌÒÓ ÛÙËÓ ·ÚÔ‡Û· ÌÂÙ·-·Ó¿Ï˘ÛË ‹Ù·Ó ·ÊÂÓfi˜ Ë Û˘ÌÌÂÙÔ¯‹ ·ÙfiÌˆÓ Ì ÁÓˆÛÙ‹ ÈÛ¯·ÈÌÈ΋ ηÚ-
‰È·Î‹ ÓfiÛÔ Î·È ·Ê’ ÂÙ¤ÚÔ˘ Ë ·Ó·Ï˘ÙÈ΋ ηٷÁÚ·Ê‹ ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ ÂÂÈÛÔ‰›ˆÓ. ∏ ·Ú·¿Óˆ ‚È‚ÏÈÔÁÚ·ÊÈ΋ ¤Ú¢ӷ η٤ÏËÍ ÛÙËÓ ·Ó‡ÚÂÛË 9 ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ÌÂÏÂÙÒÓ Ô˘ ÏËÚÔ‡Û·Ó Ù· ·Ú·¿Óˆ ÎÚÈÙ‹ÚÈ· (¶›Ó·Î·˜ 1). Ÿˆ˜ Ê·›ÓÂÙ·È ·fi ÙÔÓ ·Ú·¿Óˆ ›Ó·Î· ÛÙȘ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ Ù˘ ÌÂÙ··Ó¿Ï˘Û˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ‰È·ÊÔÚÂÙÈο ·ÓÙÈ‚ÈÔÙÈο Î·È Û ‰È·ÊÔÚÂÙÈο ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù·. ¶Ú¿ÁÌ·ÙÈ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ‰È·ÊˆÓ›Â˜ ÙfiÛÔ ÁÈ· ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· Ù˘ ·ÁˆÁ‹˜ fiÛÔ Î·È ÁÈ· ÙË ‰fiÛË ÙÔ˘ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ˘ ·ÓÙÈ‚ÈÔÙÈÎÔ‡ Ô˘ ··ÈÙÂ›Ù·È ÁÈ· ÙËÓ Ï‹ÚË ÂÎÚ›˙ˆÛË ÙÔ˘ ¯Ï·Ì˘‰›Ô˘ Ù˘ Ó¢ÌÔÓ›·˜ ·fi ÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜. Œ¯ÂÈ ‰È·Ù˘ˆı› Ë ¿Ô„Ë fiÙÈ Ë ‰È¿ÚÎÂÈ· Ù˘ ·ÁˆÁ‹˜ Ú¤ÂÈ Ó· ÍÂÂÚÓ¿ ÙÔÓ ¤Ó· Ì‹Ó·. øÛÙfiÛÔ Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ Ô˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Ì ÙË ¯ÔÚ‹ÁËÛË ·˙ÈıÚÔÌ˘Î›Ó˘, ÎÏ·ÚÈıÚÔÌ˘Î›Ó˘ 15 Î·È ÚÔÍÈıÚÔÌ˘Î›Ó˘ 16 ¯ÔÚËÁ‹ıËÎ·Ó ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· ÙˆÓ 5, ÙˆÓ 7-14 Î·È ÙˆÓ 10-14 ËÌÂÚÒÓ ·ÓÙ›ÛÙÔȯ·. ∂ÈÚfiÛıÂÙ·, ÔÈ Schneider Î·È Û˘Ó.17 ¤‰ÂÈÍ·Ó fiÙÈ Ë ·˙ÈıÚÔÌ˘Î›ÓË Û˘ÛÛˆÚ‡ÂÙ·È ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ıËڈ̷ÙÈΤ˜ ϿΘ Û ıÂڷ¢ÙÈΤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÌfiÏȘ Û 3 Ë̤Ú˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ¯ÔÚ‹ÁËÛ‹˜ Ù˘ ·fi ÙÔ ÛÙfiÌ·. ¶Ú¤ÂÈ Ó· ÂÈÛËÌ·Óı› fiÙÈ ˘¿Ú¯Ô˘Ó ·ÚÎÂÙ¤˜ ‰È·ÊˆÓ›Â˜ Î·È fiÛÔÓ ·ÊÔÚ¿ ÙË Ì¤ıÔ‰Ô ‰È¿ÁÓˆÛ˘ Ù˘ ¯ÚfiÓÈ·˜ ‚Ú·‰Â›·˜ ÂͤÏÈ͢ Ïԛ̈͢ ·fi ÙÔ ¯Ï·Ì‡‰ÈÔ Ù˘ Ó¢ÌÔÓ›·˜. √È ˘„ËÏÔ› Ù›ÙÏÔÈ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ‰ÂÓ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È ·ÍÈfiÈÛÙÔ˜ ‰Â›ÎÙ˘, ηıÒ˜ ·˘ÙÔ› ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ·Ú·Ì¤ÓÔ˘Ó ˘„ËÏÔ› ÁÈ· ·ÚÎÂÙfi ηÈÚfi ·ÎfiÌË Î·È ÌÂÙ¿ ÙËÓ ›·ÛË ÙÔ˘ ·ÛıÂÓ‹. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÌÂÙ··Ó¿Ï˘ÛË, Ï·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ¤ÎıÂÛ˘ ÙÔ˘ ÁÂÓÈÎÔ‡ ÏËı˘ÛÌÔ‡
£EPA¶EIA – °∂¡π∫∞ ¶›Ó·Î·˜ 1: ªÂϤÙ˜ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÁÈ· ÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Ù˘ π∫¡ ¢ËÌÔÛÈÂ˘Ì¤Ó˜ MÂϤÙ˜
™˘ÌÌÂÙ¤¯ÔÓÙ˜
∞ÓÙÈ‚ÈÔÙÈο
ACADEMIC,19 2000
∞ÛıÂÓ›˜ Ì ÁÓˆÛÙ‹ π∫¡ Î·È ÔÚÔıÂÙÈÎfiÙËÙ· ÁÈ· ÙÔ Ã¶
∞˙ÈıÚÔÌ˘Î›ÓË 500 mg/d po ÁÈ· 3 Ë̤Ú˜ Î·È ÌÂÙ¿ ·˙ÈıÚÔÌ˘Î›ÓË 500 mg/wk po ÁÈ· 3 Ì‹Ó˜
ROXIS,20 1999
∞ÛıÂÓ›˜ Ì ·ÛÙ·ı‹ ÛÙËı¿Á¯Ë ‹ non-Q √∂ª
ƒÔÍÈıÚÔÌ˘Î›ÓË 150 mg po bid ÁÈ· 30 Ë̤Ú˜
Gupta et al,21 1997
ÕÓ‰Ú˜ Ì ÌË ı·Ó·ÙËÊfiÚÔ √∂ª Î·È ÔÚÔıÂÙÈÎfiÙËÙ· ÁÈ· ÙÔ Ã¶
∞˙ÈıÚÔÌ˘Î›ÓË 500 mg/d po ÁÈ· 3 Ë̤Ú˜ ‹ ·˙ÈıÚÔÌ˘Î›ÓË 500 mg/d po ÁÈ· 6 Ë̤Ú˜
STAMINA,22 2002
∞ÛıÂÓ›˜ Ì √∂ª ‹ √™™
ªÂÙÚÔÓȉ·˙fiÏË 400 mg po bid ÁÈ· 7 Ë̤Ú˜ + ·˙ÈıÚÔÌ˘Î›ÓË 500 mg/d po ÁÈ· 7 Ë̤Ú˜
CLARIFY,23 2002
∞ÛıÂÓ›˜ Ì ·ÛÙ·ı‹ ÛÙËı¿Á¯Ë ‹ non-Q √∂ª
∫Ï·ÚÈıÚÔÌ˘Î›ÓË 500 mg/d po ÁÈ· 85 Ë̤Ú˜
AZACS,24 2003
∞ÛıÂÓ›˜ Ì ·ÛÙ·ı‹ ÛÙËı¿Á¯Ë ‹ √∂ª
∞˙ÈıÚÔÌ˘Î›ÓË 500 mg/d po ÁÈ· 1 Ë̤ڷ Î·È ÌÂÙ¿ 250 mg/d ÁÈ· 4 Ë̤Ú˜
ANTIBIO,25 2003
∞ÛıÂÓ›˜ Ì √∂ª
ƒÔÍÈıÚÔÌ˘Î›ÓË 300 mg/d po ÁÈ· 6 ‚‰ÔÌ¿‰Â˜
Leowattana et al,26 2001 ∞ÛıÂÓ›˜ Ì √™™ bid ÁÈ· 30 Ë̤Ú˜
ƒÔÍÈıÚÔÌ˘Î›ÓË 150 mg po
WIZARD,27 2003
∞˙ÈıÚÔÌ˘Î›ÓË 600 mg/d po ÁÈ· 3 Ë̤Ú˜ Î·È ÌÂÙ¿ 600 mg/wk po ÁÈ· 11 ‚‰ÔÌ¿‰Â˜
∞ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi √∂ª Î·È ÔÚÔıÂÙÈÎfiÙËÙ· ÁÈ· ÙÔ Ã¶
™˘ÓÙÔÌÔÁڷʛ˜: √∂ª = Ô͇ ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ √™™ = Ô͇ ÛÙÂÊ·ÓÈ·›Ô Û‡Ó‰ÚÔÌÔ π∫¡ = ÈÛ¯·ÈÌÈ΋ ηډȷ΋ ÓfiÛÔ˜ ö = ¯Ï·Ì‡‰ÈÔ Ù˘ Ó¢ÌÔÓ›·˜ Bid = 2 ÊÔÚ¤˜ ÙËÓ Ë̤ڷ
¶›Ó·Î·˜ 2: ÷ڷÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ ÙˆÓ ÌÂÏÂÙÒÓ Ã·Ú·ÎÙËÚÈÛÙÈÎfi
ÕÙÔÌ· Ô˘ Û˘ÌÌÂÙ›¯·Ó ÛÙȘ ∆∫¢
∏ÏÈΛ·, ̤ÛË ÙÈÌ‹ ± SD, ¤ÙË
64,2±12,2*
ÕÓ‰Ú˜
80,1 %
°˘Ó·›Î˜
19,9 %
∫·ÓÈÛÙ¤˜
21,0 %
ÀÂÚÙ·ÛÈÎÔ› ·ÛıÂÓ›˜
46,7 %
¢È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜
21,2 %
∞ÛıÂÓ›˜ Ì ˘ÂÚÏÈȉ·ÈÌ›·
60,8 %**
* ∂Í·ÈÚÔ‡ÓÙ·È ÔÈ ÌÂϤÙ˜ WIZARD27 Î·È ANTIBIO25 ** ∂Í·ÈÚÔ‡ÓÙ·È ÔÈ ÌÂϤÙ˜ ACADEMIC19 Î·È ANTIBIO25 ™˘ÓÙÔÌÔÁڷʛ˜: ∆∫¢ = Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ SD = ÛÙ·ıÂÚ¿ ·fiÎÏÈÛË
ÛÙÔ ¯Ï·Ì‡‰ÈÔ Ù˘ Ó¢ÌÔÓ›·˜ Â›Ó·È ÂÚ›Ô˘ 50%18, ·ÔÊ·Û›ÛıËΠӷ ÌËÓ ÂÍ·ÈÚÂı› η̛· ÌÂϤÙË Ì ÎÚÈÙ‹ÚÈÔ ÙËÓ ÔÚÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢. ∆¤ÏÔ˜, ÂÍ·ÈÙ›·˜ ÙÔ˘ ÁÂÁÔÓfiÙÔ˜ fiÙÈ Ù· ‰Â‰Ô̤ӷ Ô˘ Û˘Û¯ÂÙ›˙Ô˘Ó ÙËÓ ÌË Î·Ú‰È·Î‹ ·ÁÁÂȷ΋ ÓfiÛÔ (ÂÚÈÊÂÚÈ΋ ·ÚÙËÚÈÔ¿ıÂÈ· Î·È ÂÁÎÂÊ·ÏÈ΋ ·ÁÁÂȷ΋ ÓfiÛÔ) Ì ÙË Ïԛ̈ÍË ·fi ÙÔ ¯Ï·Ì‡‰ÈÔ Ù˘ Ó¢ÌÔÓ›·˜ Â›Ó·È ·Ó·Ú΋, Ë ÌÂÙ·-·Ó¿Ï˘ÛË ÂÈÎÂÓÙÚÒıËΠ۠ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ Û˘ÌÌÂÙ›¯·Ó ¿ÙÔÌ· Ì ÁÓˆÛÙ‹ ÌfiÓÔ ÈÛ¯·ÈÌÈ΋ ηډȷ΋ ÓfiÛÔ Î·È ÛÙȘ Ôԛ˜ Ù· ·ÚÈ· ηٷÏËÎÙÈο ÛËÌ›· ·ÔÙÂÏÔ‡Û·Ó ÌfiÓÔ Ù· ÛÙÂÊ·ÓÈ·›· ÎÏÈÓÈο Û‡Ó‰ÚÔÌ·, fiˆ˜ ÙÔ Ô͇ ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘, Ë ·ÛÙ·ı‹˜ ÛÙËı¿Á¯Ë Î·È Ô ·ÈÊÓ›‰ÈÔ˜ ηډȷÎfi˜ ı¿Ó·ÙÔ˜. ∂ÓÓ¤· ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÌÂϤÙ˜ ÛÙȘ Ôԛ˜ Û˘ÌÌÂÙ›¯·Ó Û˘ÓÔÏÈο 11.015 ¿ÙÔÌ·, ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· ¤ÓÙ·Í˘ ÛÙË Û˘ÁÎÂÎÚÈ̤ÓË ÌÂÙ·-·Ó¿Ï˘ÛË. ™ÙÔÓ ¶›Ó·Î· 2 Ê·›ÓÔÓÙ·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÙfiÌˆÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ·˘Ù¤˜ ÙȘ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜. ™Â ¤ÍÈ ·fi ÙȘ ÌÂϤÙ˜ ·Ú·ÙËÚÂ›Ù·È Ì›· Û·Ê‹˜ ˘ÂÚÔ¯‹ ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·Ó‰ÚÒÓ Û ۇÁÎÚÈÛË Ì ÙȘ Á˘Ó·›Î˜, ÂÓÒ Û ·ÚÎÂÙ¤˜ ÌÂϤÙ˜ ‰ÂÓ ·Ú¤¯ÔÓÙ·Ó ·ÚÎÂÙ¿ ÛÙÔȯ›· fiÛÔÓ ·ÊÔÚ¿ ÙÔ Ê‡ÏÔ ÙˆÓ ·ÙfiÌˆÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ·˘Ù¤˜. ∞Ó·ÊÔÚÈο Ì ٷ ·ÔÙÂϤÛÌ·Ù·, Ù¤ÛÛÂÚȘ ·fi ÙȘ ·Ú·¿Óˆ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó ¤Ó· ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙËÓ ÚfiÏË„Ë ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ. øÛÙfiÛÔ, ¤ÓÙÂ Ù˘¯·ÈÔÔÈË̤Ó˜ ÎÏÈÓÈΤ˜ ‰ÔÎÈ̤˜ ‰ÂÓ ¤‰ÂÈÍ·Ó Î·Ó¤Ó· fiÊÂÏÔ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÚfiÏË„Ë ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ Û˘Ì‚·Ì¿ÙˆÓ Î·È ÙˆÓ ·ÈÊÓ›‰ÈˆÓ ηډȷÎÒÓ ı·Ó¿ÙˆÓ. ∞Ó¿ÌÂÛ· Û ·˘Ù¤˜, Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·È ÔÈ ÌÂϤÙ˜ WIZARD27, AZACS24 Î·È ANTIBIO25 ÔÈ Ôԛ˜, ÂÍ·ÈÙ›·˜ ÙÔ˘ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ·ÙfiÌˆÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ·˘Ù¤˜ (72% ÙÔ˘ Û˘ÓfiÏÔ˘ ÁÈ· ÙË ÌÂϤÙË WIZARD Î·È 14% ÁÈ· ÙȘ ÌÂϤÙ˜ AZACS Î·È ANTIBIO), ›¯·Ó Î·È ÙË ÌÂÁ·Ï‡ÙÂÚË ‚·Ú‡ÙËÙ· ÛÙË ‰È·ÌfiÚʈÛË ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜ Ù˘ ÌÂÙ·-·Ó¿Ï˘Û˘.
19
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
∫·Ù¿ Û˘Ó¤ÂÈ·, ÙÔ Û˘ÓÔÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ ÌÂÙ·-·Ó¿Ï˘Û˘ ‰ÂÓ Û˘ÓËÁÔÚ› ˘¤Ú οÔÈÔ˘ ÏÂÔÓÂÎÙ‹Ì·ÙÔ˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ÚfiÏË„Ë ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ 0,94 [95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜, 0,86-1,03]) ‹ ÙË Ì›ˆÛË Ù˘ ηډȷÁÁÂȷ΋˜ ıÓËÙfiÙËÙ·˜ (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ 0,94 [95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜, 0,791,12]). ∆· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÓÓ¤· Ù˘¯·ÈÔÔÈËÌ¤ÓˆÓ ÎÏÈÓÈÎÒÓ ‰ÔÎÈÌÒÓ, ηıÒ˜ Î·È ÙÔ Û˘ÓÔÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Ù˘ ÌÂÙ·-·Ó¿Ï˘Û˘ Ê·›ÓÔÓÙ·È ‰È·ÁÚ·ÌÌ·ÙÈο ÛÙ· ™¯‹Ì·Ù· 1 Î·È 2. Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙ· ™¯‹Ì·Ù· 1 Î·È 2 Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ·ÛıÂÓ›˜ Ì ÁÓˆÛÙ‹ ÈÛ¯·ÈÌÈ΋ ηډȷ΋ ÓfiÛÔ ‰ÂÓ Ô‰‹ÁËÛ Û Ì›ˆÛË ÙˆÓ Î·Ú‰È·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ ‹ Ù˘ ıÓËÙfiÙËÙ·˜. √È ÌÂϤÙ˜ ÔÈ Ôԛ˜ ¤‰ÂÈÍ·Ó ¤Ó· Û˘ÁÎÚÈÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Â›¯·Ó ÛËÌ·ÓÙÈο ÌÂıÔ‰ÔÏÔÁÈο ÛÊ¿ÏÌ·Ù· Î·È ¤Ó· ÂÍ·ÈÚÂÙÈο ÛËÌ·ÓÙÈÎfi ÛÊ¿ÏÌ· Ù‡Ô˘ π ÂÍ·ÈÙ›·˜ ÙÔ˘ ÌÈÎÚÔ‡ ·ÚÈıÌÔ‡ ·ÙfiÌˆÓ Ô˘ Û˘ÌÌÂÙ›¯·Ó Û ·˘Ù¤˜. ™˘ÓÔÏÈο, Ë ÌÂÙ·-·Ó¿Ï˘ÛË ·˘Ù‹ ¤‰ÂÈÍ fiÙÈ Ù· ·ÓÙÈ‚ÈÔÙÈο ‰ÂÓ ¤¯Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ‰Â˘ÙÂÚÔÁÂÓ‹ ÚfiÏË„Ë Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘. øÛÙfiÛÔ, οÙÈ Ù¤ÙÔÈÔ ‰ÂÓ ÛËÌ·›ÓÂÈ fiÙÈ ÔÈ ÏÔÈÌÒÍÂȘ ‰ÂÓ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÂͤÏÈÍË Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ·ıËÚÔÛÎÏ‹ÚˆÛ˘, Ô‡ÙÂ Î·È fiÙÈ Ù· ·ÓÙÈ‚ÈÔÙÈο ‰ÂÓ ÂÓ‰¤¯ÂÙ·È Ó· ·ÔÎÙ‹ÛÔ˘Ó ÛÙÔ Ì¤ÏÏÔÓ Î¿ÔÈÔ ÚfiÏÔ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘. ¶Èı·ÓÒ˜, ‰È·ÊÔÚÂÙÈο ·ÓÙÈ‚ÈÔÙÈο ‹ ¤ÛÙˆ ‰È·ÊÔÚÂÙÈο ‰ÔÛÔÏÔÁÈο Û¯‹Ì·Ù· Ó· ·Ô‰ÂȯÙÔ‡Ó ÛÙÔ Ì¤ÏÏÔÓ ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈο. ∂›Û˘, Ë ÌÂÙ·-·Ó¿Ï˘ÛË ·˘Ù‹ ‰ÂÓ ·ÍÈÔÏfiÁËÛ ÙËÓ ÈηÓfiÙËÙ· ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Ó· ÂÈ‚Ú·‰‡ÓÔ˘Ó ÙËÓ ÂͤÏÈÍË ÙˆÓ ·ıËڈ̷ÙÈÎÒÓ ‚Ï·‚ÒÓ, Ô‡Ù ÙÔÓ Èı·Ófi ÚfiÏÔ Ô˘ ÌÔÚ› ·˘Ù¿ Ó· ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÛÙËÓ ÚˆÙÔÁÂÓ‹ ÚfiÏË„Ë Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘. ∂Èο˙ÂÙ·È fiÙÈ Ë ¯Ú‹ÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ÌÈÎÚfiÙÂÚ˜ ËÏÈ˘ Â›Ó·È ‰˘Ó·Ùfi Ó· Û˘Ì‚¿ÏÂÈ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ·ıËÚÔÛÎÏ‹ÚˆÛ˘. ∂ÈÚfiÛıÂÙ·, Û οÔȘ ·fi ÙȘ ÌÂ-
20
™¯‹Ì· 1. ∞ÔÙ¤ÏÂÛÌ· Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ fiÛÔÓ ·ÊÔÚ¿ ÙË Ì›ˆÛË ÙˆÓ Î·Ú‰È·ÁÁÂÈ·ÎÒÓ Û˘Ì‚·Ì¿ÙˆÓ (·ÛÙ·ı‹˜ ÛÙËı¿Á¯Ë, Ô͇ ¤ÌÊÚ·ÁÌ· ÙÔ˘ Ì˘Ôηډ›Ô˘ ‹ ·ÈÊÓ›‰ÈÔ˜ ηډȷÎfi˜ ı¿Ó·ÙÔ˜). ™¯ÂÙÈ΋ µ·Ú‡ÙËÙ· ∂ÚÁ·Û›·
™‡ÓÔÏÔ (95% Cl)
À¤Ú Ù˘ ıÂڷ›·˜
À¤Ú Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘
™˘ÓÙÔÌÔÁڷʛ˜: CI : fiÚÈ· ·ÍÈÔÈÛÙ›·˜ RR: Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜
™¯‹Ì· 2. ∞ÔÙ¤ÏÂÛÌ· Ù˘ ¯ÔÚ‹ÁËÛ˘ ·ÓÙÈ‚ÈÔÙÈÎÒÓ fiÛÔÓ ·ÊÔÚ¿ ÙËÓ Î·Ú‰È·ÁÁÂȷ΋ ıÓËÙfiÙËÙ· ™¯ÂÙÈ΋ µ·Ú‡ÙËÙ· ∂ÚÁ·Û›·
™‡ÓÔÏÔ (95% Cl)
À¤Ú Ù˘ ıÂڷ›·˜
À¤Ú Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘
™˘ÓÙÔÌÔÁڷʛ˜: CI : fiÚÈ· ·ÍÈÔÈÛÙ›·˜ RR: Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜
ϤÙ˜ Ê¿ÓËΠfiÙÈ Î¿ÔȘ ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ ¢ÓÔ‹ıËÎ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ۇÁÎÚÈÛË Ì ÔÚÈṲ̂Ó˜ ¿ÏϘ. °È· ·Ú¿‰ÂÈÁÌ·, ÛÙË ÌÂϤÙË WIZARD27 ÔÈ ‰È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ ¢ÓÔ‹ıËÎ·Ó ÂÚÈÛÛfiÙÂÚÔ ·fi ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈÎÒÓ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ÌË ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜. ª¤Û· ÛÙ· ÂfiÌÂÓ· 2 ¯ÚfiÓÈ· ›ÎÂÈÙ·È Ë ‰ËÌÔÛ›Â˘ÛË Î·È ¿ÏψÓ
ÌÂÁ¿ÏˆÓ ÌÂÏÂÙÒÓ ÁÈ· ÙËÓ ·ÍÈÔÏfiÁËÛË ÙÔ˘ Èı·ÓÔ‡ ÚfiÏÔ˘ ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙËÓ ÚfiÏË„Ë Ù˘ ÈÛ¯·ÈÌÈ΋˜ ηډȷ΋˜ ÓfiÛÔ˘. ∂ÈϤÔÓ, ÂÚÂ˘Ó¿Ù·È Ô Èı·Ófi˜ ÚfiÏÔ˜ ÙˆÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ ÛÙËÓ ÂÈ‚Ú¿‰˘ÓÛË Ù˘ ¤ÎÙ·Û˘ ÙˆÓ ·Ó¢ڢÛÌ¿ÙˆÓ Ù˘ ÎÔÈÏȷ΋˜ ·ÔÚÙ‹˜28 Î·È Ù˘ ÂͤÏÈ͢ Ù˘ ·ıËÚÔÛÎÏ‹ÚˆÛ˘ ÙˆÓ Î·ÚˆÙ›‰ˆÓ29.
£EPA¶EIA – °∂¡π∫∞ µÈ‚ÏÈÔÁÚ·Ê›· 1.
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10. Luchsinger JA, Pablos-Mendez A, Knirsch C, Rabinowitz D, Shea S. Relation of antibiotic use to risk of myocardial infarction in the general population. Am J Cardiol 2002;89:18-21. 11. Meier CR, Derby LE, Jick SS, Vasilakis C, Jick H. Antibiotics and risk of subsequent first-time acute myocardial infarction. JAMA 1999;281:427-431
12. Ostergaard L, Sorensen HT, Lindholt J, et al. Risk of hospitalization for cardiovascular disease after use of macrolides and penicillins: a comparative prospective cohort study. J Infect Dis 2001;183: 1625-1630. 13. Erkens JA, Klungel OH, Herings RMC, et al. Use of fluorquinolones is associated with a reduced risk of coronary heart disease in diabetes mellitus type II patients. Eur Heart J 2002;23:15751579. 14. Jackson LA, Smith NL, Heckbert SR, Grayston JT, Siscovick DS, Psaty BM. Past use of erythromycin, tetracycline, or doxycycline is not associated with risk of first myocardial Infarction. J Infect Dis 2000;181:S563-S565. 15. Gilbert DN, Moellering RC Jr, Sande MA. The Sanford Guide to Antimicrobial Therapy. 23rd ed. Hyde Park, Vt: Antimicrobial Therapy Inc; 2003. 16. Ortqvist A, Valtonen M, Cars O, Wahl M, Saikku P, Jean C. Oral empiric treatment of community-acquired pneumonia: a multicenter, double-blind, randomized study comparing sparfloxacin with roxithromycin. Chest 1996;110: 1499-1506. 17. Schneider CA, Diedrichs H, Riedel KD, et al. In vivo uptake of azithromycin in human coronary plaques. Am J Cardiol 2000;86:789-791. 18. Aldous MB, Grayston JT, Wang SP, Foy HM. Seroepidemiology of Chlamydia pneumoniae TWAR infection in Seattle families, 1966-79. J Infect Dis 1992; 166:646-649. 19. Muhlestein JB, Anderson JL, Carlquist JF. Randomized secondary prevention trial of azithromycin in patients with coronary artery disease: primary clinical results of the ACADEMIC Study. Circulation 2000;102:1755-1760 20. Gurfinkel E, Bozovich G, Beck E, Testa E, Livellara B, Mautner B. Treatment with the antibiotic roxithromycin in patients with acute non-Q-wave coronary syndromes: the final report of the ROXIS Study. Eur Heart J 1999;20:121127. 21. Gupta S, Leatham EW, Carrington D, Mendall MA, Kaski JC, Camm AJ. Elevated Chlamydia pneumoniae antibodies, cardiovascular events, and azithromycin in male survivors of myocardial infarction. Circulation 1997;96:404407.
22. Stone AFM, Mendall MA, Kaski JC, et al. Effect of treatment for Chlamydia pneumoniae and Helicobacter pylori on markers of inflammation and cardiac events in patients with acute coronary syndromes: South Thames Trial of Antibiotics in Myocardial Infarction and Unstable Angina (STAMINA). Circulation 2002; 106: 1219-1223. 23. Sinisalo J, Mattila K, Valtonen V, et al, Clarithromycin in Acute Coronary Syndrome Patients in Finland (CLARIFY) Study Group. Effect of 3 months of antimicrobial treatment with clarithromycin in acute non-Q-wave coronary syndrome. Circulation 2002;105:1555-1560. 24. Cercek B, Shah PK, Noc M, et al. Effect of short-term treatment with azithromycin on recurrent ischaemic events in patients with acute coronary syndrome in the Azithromycin in Acute Coronary Syndrome (AZACS) trial: a randomised controlled trial. Lancet 2003;361:809813. 25. Zahn R, Schneider S, Frilling B, et al, Working Group of Leading Hospital Cardiologists (ALKK). Antibiotic therapy after acute myocardial infarction: a prospective randomized study. Circulation 2003; 107:1253-1259. 26. Leowattana W, Bhuripanyo K, Singhaviranon L, et al. Roxithromycin in prevention of acute coronary syndrome associated with Chlamydia pneumoniae infection: a randomized placebo controlled trial. J Med Assoc Thai 2001;84: S669-S675. 27. O’Connor CM, Dunne MW, Pfeffer MA, et al. Azithromycin for the secondary prevention of coronary heart disease events: the Wizard Study: a randomized controlled trial. JAMA 2003;290:14591466. 28. Vammen S, Lindholt JS, Ostergaard L, et al. Randomized double-blind controlled trial of roxithromycin for treatment of abdominal aortic aneurysm expansion. Br J Surg 2001;88:1066-1072. 29. Sander D, Winbeck K, Klingelhofer J, Etgen T, Conrad B. Reduced progression of early carotid atherosclerosis after antibiotic treatment and Chlamydia pneumoniae seropositivity. Circulation 2002;106:2428-2433.
21
·ıËÚÔÛÎÏ‹ÚˆÛË ¢∂∫∂ªµƒπ√™ 2005
¶ƒ√∆∂π¡√ª∂¡∏ µπµ§π√°ƒ∞ºπ∞ 1:
Djaldetti M, Salman H, Bergman M, Bessler H. Effect of pravastatin, simvastatin and atorvastatin on the phagocytic activity of mouse peritoneal macrophages. Exp Mol Pathol. 2005 Oct 31; [Epub ahead of print]
2:
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 Nov;11(11):670-4.
3:
4:
Qu C, Lu D, Goussev A, Schallert T, Mahmood A, Chopp M. Effect of atorvastatin on spatial memory, neuronal survival, and vascular density in female rats after traumatic brain injury. J Neurosurg. 2005 Oct;103(4):695-701. [No authors listed] Increased clinical benefit of atorvastatin at high doses in stable coronary heart disease. Nat Clin Pract Cardiovasc Med. 2005 May 24;2(6):272 [Epub ahead of print]
5:
Gulec S, Ozdol C, Rahimov U, Atmaca Y, Kumbasar D, Erol C. Myonecrosis after elective percutaneous coronary intervention: effect of clopidogrel-statin interaction. J Invasive Cardiol. 2005 Nov;17(11):589-93.
6:
Matzno S, Yasuda S, Juman S, Yamamoto Y, Nagareya-Ishida N, TazuyaMurayama K, Nakabayashi T, Matsuyama K. Statin-induced apoptosis linked with membrane farnesylated Ras small G protein depletion, rather than geranylated Rho protein. J Pharm Pharmacol. 2005 Nov;57(11):1475-84.
7:
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