Malattie respiratorie e fattori di rischio cardiovascolare

Dr. Alessandro Grembiale

ULSS 10 Veneto Orientale P.O. San Donà di Piave

UOC Medicina Generale

Asma e BPCO

Asma Prevalenza: 1 – 20 % BPCO:Prevalenza : 5- 22%

BPCO e mortalità

COPD is a worldwide epidemic COPD is the fourth leading cause of death in the world Its prevalence ranges between 6% and 19,7%

Mortality rates for COPD have jumped by > 163%, and will increase by 50% in the next 15 years

World Health Report. Geneva: World Health Organization. Available from URL: http://www.who.int/whr/2000/en/ statistics.htm; 2000. Lopez AD, et al. “Chronic obstructive pulmonary disease: current burden and future projections.”, Eur Respir J. 2006 Feb;27(2):397-412.

Vestbo J, et al. “Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary”, Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65. doi: 10.1164/rccm.201204-0596PP. Epub 2012 Aug 9.Review. PubMed PMID: 22878278. – Update 2015

COPD Comorbidome

Multimorbidità

Multi

morbidità

Infiammazione sistemica Aging

Politerapia

Interazioni farmacologiche

Fattori di rischio

Tabagismo

Multimorbidità

• Condivisione di meccanismi fisiopatologici

• Fenotipizzazione

• Impatto sulle risorse sanitarie

• Mortalità

Classificazione Multimorbidità

Approccio clinico patologico Respiratorio Asma, polmonite, fibrosi polmonare, embolia polmonare, OSAS

Cardiovascolari Ipertensione arteriosa, cardiopatia ischemica, ictus, scompenso cardiaco

Metaboliche Sindrome metabolica, diabete, dislipidemia, obesità

Oncologiche K polmone, K esofago, K mammella

Condivisione del meccanismo patologico Infiammazione Asma, polmonite, cardiopatia ischemica, ipertensione , sindrome

metabolica

Necrosi/ degenerazione

Malattie cardiovascolari, osteoporosi, MRGE

Metaboliche Sindrome metabolica, diabete, dislipidemia

Riparazione/ proliferazione cellulare

K polmone, K esofago, K mammella, disfunzione muscolo scheletrica,

Trombosi/ emorragia

Embolia polmonare, malattie cerebrovascolari.

BPCO, Ipertensione arteriosa e Diabete

STUDIO ETA’ PAZIENTE DIABETE MELLITO TIPO 2 (%)

IPERTENSIONE ARTERIOSA (%)

MAPEL 67 12 45

VAN MANEN 66 5 23

WALSH 16 52

MANNINO 57 13 40

Prevalenza malattie cardiovascolari e Diabete (studio ARNO)

CVD

Diabete

BPCO, Ipertensione arteriosa e Diabete

Coorti ARIC (Atherosclerosis Risk in Communities Study) e

CHS (Cardiovascular Health Study)

Età Diabete Mellito (%) Ipertensione arteriosa (%)

45-49 8 24

50- 54 10,6 32

55-59 12,9 38,1

60-64 16,5 46,4

65-71 16,2 49,9

72-75 13,9 51,3

76-79 15,9 58

>80 15,4 62

D.M. Mannino Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD Eur Respir J 2008; 32: 962–969

Diabete Mellito (%) Ipertensione arteriosa (%)

Prevalenza media

12 40

BPCO, Ipertensione arteriosa e Diabete

Coorti ARIC (Atherosclerosis Risk in Communities Study) e

CHS (Cardiovascular Health Study)

D.M. Mannino Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD Eur Respir J 2008; 32: 962–969

Sindrome Metabolica

Rischio Cardiovascolare

Diabete Mellito tipo 2

Sindrome Metabolica: definizioni

BPCO e Sindrome Metabolica

Origine studio Prevalenza SM in BPCO (%)

Grecia 21

Corea 33 (M) – 49 (F)

Turchia 27

Canada 47

Germania GOLD I 50 GOLD II 53 GOLD III 37 GOLD IV 44

Francia 50

SM in BPCO (%)

Prevalenza media 20 - 50

INDACO project

Fumagalli et al. INDACO project: a pilot study on incidence of comorbidities in COPD patients referred to pneumology units Multidisciplinary Respiratory Medicine 2013, 8:28

Fumagalli et al. INDACO project: COPD and link between comorbidities, lung function and inhalation therapy Multidisciplinary Respiratory Medicine 2015, 10:4

INDACO project

Fumagalli et al. INDACO project: a pilot study on incidence of comorbidities in COPD patients referred to pneumology units Multidisciplinary Respiratory Medicine 2013, 8:28

Fumagalli et al. INDACO project: COPD and link between comorbidities, lung function and inhalation therapy Multidisciplinary Respiratory Medicine 2015, 10:4

Asma e BPCO: quadri patologici classici

Dirkje S. Postma, Klaus F. Rabe The Asthma–COPD Overlap Syndrome N Engl J Med 2015;373:1241-9.

Transizione demografica

Asma, ipertensione e Diabete

A. Wardzynska Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment Geriatr Gerontol Int 2015; 15: 902–909

Asma, ipertensione e Diabete

Asma e sindrome metabolica

Walter RE, Beiser A, Givelber RJ, O'Connor GT, Gottlieb DJ. Association between glycemic state and lung function: the Framingham Heart Study. Am J Respir Crit Care Med 2003;167:911-6.

Davis WA, Knuiman M, Kendall P, Grange V, Davis TM; Fremantle Diabetes Study. Glycemic exposure is associated with reduced pulmonary function in type 2 diabetes: the Fremantle Diabetes Study. Diabetes Care 2004;27:752-7.

• Several epidemiological studies have shown that elevated insulin level and insulin resistance were associated with decreased lung function.

• Obesity and asthma may be related through common inflammatory pathways associated with insulin resistance.

Asma e sindrome metabolica

Asma e sindrome metabolica

Asma e sindrome metabolica

Asma e sindrome metabolica

• fasting insulin level and HOMA-IR had significant correlation with FEV1 (%) (r = –0.1440, p=0.011, and r = –0.1156, p = 0.042, respectively).

Asma e sindrome metabolica

Definizioni attuali

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment (GINA 2011).

COPD, a common preventable and treatable disease, is characterised by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases Exacerbations and comorbidities contribute to the overall severity in individual patients (GOLD 2011)

Vanfleteren LEGW, Kocks JWH, Stone IS, et al. Moving from the Oslerian paradigm to the postgenomic era: are asthma and COPD outdated terms?

Thorax 2014;69:72–79.

Mast cell

CD4+ cell (Th2)

Eosinophil

Allergens

Ep cells

ASTHMA

Bronchoconstriction AHR

Alv macrophage Ep cells

CD8+ cell (Tc1)

Neutrophil

Cigarette smoke

Small airway narrowing Alveolar destruction

COPD

Reversible Irreversible Airflow Limitation

Fattori di rischio per lo sviluppo di malattie croniche

Principali Comportamentali Metabolici

Aging Fumo Ipertensione arteriosa

Infiammazione Sedentarità Sovrappeso ed obesità

Abuso di alcol Dislipidemia

Dieta non corretta

Liver IL-6, TNF-α, IL-1β IL-6

CRP

Cardiovascular disease Muscle wasting

Skeletal muscle

Other Inflammatory diseases

Circulation

Infiammazione sistemica

Senectus ipsa morbu

De Martinis M, Franceschi C, et al. Inflammation markers predicting frailty and mortality in the elderly.” Exp Mol Pathol. 2006 Jun;80(3):219-27.

“Il giovane medico comincia la sua professione prescrivendo

venti medicine per ogni malanno, quello vecchio finisce

per prescriverne una sola per venti malanni.”

Sir William Osler

Grazie per l’attenzione