Medicina Integrada
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Siguiendo el mismo tenero del artículo previo, envío dos artículos nuevos para su publicación, uno de a mediados del mes pasado, publicado en la revista Lancet, en él se analiza el papel de los lípidos, apolipoproteínas y lipoproteínas como marcadores para el riesgo de enfermedades cardiovasculares. Para ello se realizó un estudio de casos y controles en 52 países, incluido México, les dejo el resumen para que lo conozcan:
Pueden discutir el caso en: http://www.medicinaintegrada.org.mx/foros/topic.php?id=25
Para descargarlo: http://www.thelancet.com/journals/lancet/article/PIIS0140673608610764/abstract
Lancet 2008; 372: 224–33
Background Whether lipoproteins are better markers than lipids and lipoproteins for coronary heart disease is widely debated. Our aim was to compare the apolipoproteins and cholesterol as indices for risk of acute myocardial infarction.
Methods We did a large, standardised case-control study of acute myocardial infarction in 12 461 cases and
14 637 age-matched (plus or minus 5 years) and sex-matched controls in 52 countries. Non-fasting blood samples were available from 9345 cases and 12 120 controls. Concentrations of plasma lipids, lipoproteins, and apolipoproteins were measured, and cholesterol and apolipoprotein ratios were calculated. Odds ratios (OR) and 95% CI, and population-attributable risks (PARs) were calculated for each measure overall and for each ethnic group by comparison of the top four quintiles with the lowest quintile.
Findings The apolipoprotein B100 (ApoB)/apolipoprotein A1 (ApoA1) ratio had the highest PAR (54%) and the highest OR with each 1 SD diff erence (1·59, 95% CI 1·53–1·64). The PAR for ratio of LDL cholesterol/HDL cholesterol was 37%. PAR for total cholesterol/HDL cholesterol was 32%, which was substantially lower than that of the ApoB/ApoA1 ratio (p<0·0001). These results were consistent in all ethnic groups, men and women, and for all ages.
Interpretation The non-fasting ApoB/ApoA1 ratio was superior to any of the cholesterol ratios for estimation of the risk of acute myocardial infarction in all ethnic groups, in both sexes, and at all ages, and it should be introduced into worldwide clinical practice.
Funding Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario, the International Clinical Epidemiology Network (INCLEN). Unrestricted grants from pharmaceutical companies (with major contributions from AstraZeneca, Novartis, Aventis, Abbott, Bristol Myers Squibb, King Pharma, and Sanofi -Synthelabo), and by various national bodies.
Por otro lado tenemos un artículo publicado en la revista Mayo Clinic Proceedings este mes, en él se analizan los efecto de una terapia intensiva para disminuir los lípidos comparado con métodos menos agresivos, para ello se utilizó atorvastatina a dosis diferentes:
Para discutir el artículo: http://www.medicinaintegrada.org.mx/foros/topic.php?id=26
Puedes descargarlo en: http://www.mayoclinicproceedings.com/inside.asp?AID=4745
Mayo Clin Proc. 2008;83(8):870-879
Objetive: To investigate the effect of intensive lipid lowering with high-dose atorvastatin on the incidence of major cardiovascular events compared with low-dose atorvastatin in patients with coronary artery disease and type 2 diabetes, with and without chronic kidney disease (CKD).
Patients and Methods: Following 8 weeks’ open-label therapy with atorvastatin (10 mg/d), 10,001 patients with coronary artery disease were randomized to receive double-blind therapy with either 80 mg/d or 10 mg/d of atorvastatin between July 1, 1998, and December 31, 1999. Of 1501 patients with diabetes, renal data were available for 1431. Patients with CKD were defined as having a baseline estimated glomerular filtration rate (eGFR) below 60 mL/min per 1.73 m2, using the Modification of Diet in Renal Disease equation.
Rersults: After a median follow-up of 4.8 years, 95 (17.4%) of 546 patients with diabetes and CKD experienced a major cardiovascular event vs 119 (13.4%) of 885 patients with diabetes and normal eGFRs (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.00-1.72; P<.05). Compared with 10 mg of atorvastatin, 80 mg of atorvastatin reduced the relative risk of major cardiovascular events by 35% in patients with diabetes and CKD (20.9% [57/273] vs 13.9% [38/273]; HR, 0.65; 95% CI, 0.43-0.98; P=.04) and by 10% in patients with diabetes and normal eGFR (14.1% [62/441] vs 12.8% [57/444]; HR, 0.90; 95% CI, 0.63-1.29; P=.56). The absolute risk reduction in patients with diabetes and CKD was substantial, yielding a number needed to treat of 14 to prevent 1 major cardiovascular event over 4.8 years. Both treatments werewell tolerated.
Conclusions: Patients with diabetes, stable coronary artery disease, and mild to moderate CKD experience marked reduction in cardiovascular events with intensive lipid lowering, in contrast to previous observations in patients with diabetes and end-stage renal disease.
Roberto Sánchez Torre el 2 Agosto 2008
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Guías y Artículos, Medicina Integrada
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En esta ocasión quisiera proponer un análisis de un artículo publicado en el Mayo Clinic Proceedings, en él se analizan los beneficios de los cambios en el estilo de vida, de los conocemos de sobra su importancia y programas como UNEME SORID les da un papel importante, contra el uso de la Simvastatina, los resultados favorecen al tratamiento “no” médico, pero creo que debemos ser muy analíticos a la hora de leer artículos como el que aquí propongo y que espero genere una rica discusión, ya que al menos en mi parecer los medicamentos tienen un papel importante en el tratamiento de las dislipidemias y aunque en este caso se trata de un Estudio de Prevención Primaria, dejan entrever si no se tiene cuidado al analizar la información, llevandonos a la idea equivocada de que se trata de una alternativa directa al uso de medicamentos en el tratamiento, ¿qué opinan?
Espero sus comentarios en el foro: http://www.medicinaintegrada.org.mx/foros/topic.php?id=24
Este artículo puede ser descargado en: http://www.mayoclinicproceedings.com/pdf/8307/8307a.pdf
Mayo Clin Proc. 2008;83(7):758-764
Objetive: To compare the lipid-lowering effects of an alternative regimen (lifestyle changes, red yeast rice, and fish oil) with a standard dose of a 3-hydroxy-3-methylglutaryl coenzyme A reductase
inhibitor (statin).
Patients and Methods: This randomized trial enrolled 74 patients with hypercholesterolemia who met Adult Treatment Panel III criteria for primary prevention using statin therapy. All participants
were randomized to an alternative treatment group (AG) or to receive simvastatin (40 mg/d) in this open-label trial conducted between April 1, 2006, and June 30, 2006. The alternative
treatment included therapeutic lifestyle changes, ingestion of red yeast rice, and fish oil supplements for 12 weeks. The simvastatin group received medication and traditional counseling. The primary
outcome measure was the percentage change in low-density lipoprotein cholesterol (LDL-C). Secondary measures were changes in other lipoproteins and weight loss.
Results: There was a statistically significant reduction in LDL-C levels in both the AG (–42.4%±15%) (P<.001) and the simvastatin group (–39.6%±20%) (P<.001). No significant differences were
noted between groups. The AG also demonstrated significant reductions in triglycerides (–29% vs –9.3%; 95% confidence interval, –61 to –11.7; P=.003) and weight (–5.5% vs –0.4%; 95%
confidence interval, –5.5 to –3.4; P<.001) compared with the simvastatin group.
Conclusion: Lifestyle changes combined with ingestion of red yeast rice and fish oil reduced LDL-C in proportions similar to standard therapy with simvastatin. Pending confirmation in larger
trials, this multifactorial, alternative approach to lipid lowering has promise for a subset of patients unwilling or unable to take statins.
Roberto Sánchez Torre el 1 Agosto 2008
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Actualización, Crónico-degenerativas, Guías y Artículos, Medicina Integrada
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Uno de los objetivos principales de formar una Sociedad Científica, bajo el término que se le quiera dar, es la actualización, y este medio es excelente para hacerlo, es por ello que vuelvo a lazar esta propuesta de hacer uso de la hemeroteca, revisar artículos y comentarlos. Creo en definitiva que es una forma más, y muy efectiva, de darnos a conocer, y darle fuerza a nuestra especialidad.
Es por ello que vuelvo a proponer un artículo, en esta ocasión toca a uno publicado en la revista JAMA, el título: Anckle Branchial Index Combined With Framingham Risk Score to Predict Cardiovascular Events and Mortality
En esta ocasión cambiaré la dinámica. Unicamente se publicará el Abstract en su idioma original para evitar errores y se abrirá un foro de discusión con el mismo título con la finalidad de discutirlo entre todos:
Foro de discusión: http://www.medicinaintegrada.org.mx/foros/topic.php?id=22
Se puede descargar el artículo en este enlace: http://jama.ama-assn.org/cgi/content/abstract/300/2/197
A Meta-analysis
Ankle Brachial Index Collaboration
JAMA. 2008;300(2):197-208.
Context Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index (ABI) is an indicator of atherosclerosis and has the potential to improve prediction.
Objective To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score (FRS) and can improve risk prediction.
Data Sources Relevant studies were identified. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies.
Study Selection Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality.
Data Extraction Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta-analysis was conducted on individuals who had no previous history of coronary heart disease.
Results Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480 325 person-years of follow-up of 24 955 men and 23 339 women, the risk of death by ABI had a reverse J-shaped distribution with a normal (low risk) ABI of 1.11 to 1.40. The 10-year cardiovascular mortality in men with a low ABI (?0.90) was 18.7% (95% confidence interval [CI], 13.3%-24.1%) and with normal ABI (1.11-1.40) was 4.4% (95% CI, 3.2%-5.7%) (hazard ratio [HR], 4.2; 95% CI, 3.3-5.4). Corresponding mortalities in women were 12.6% (95% CI, 6.2%-19.0%) and 4.1% (95% CI, 2.2%-6.1%) (HR, 3.5; 95% CI, 2.4-5.1). The HRs remained elevated after adjusting for FRS (2.9 [95% CI, 2.3-3.7] for men vs 3.0 [95% CI, 2.0-4.4] for women). A low ABI (?0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women.
Conclusion Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.
Ankle Brachial Index Collaboration Authors: F. G. R. Fowkes , G. D. Murray , I. Butcher , C. L. Heald , R. J. Lee (coordinating center); L. E. Chambless , A. R. Folsom , A. T. Hirsch (Atherosclerosis Risk in Communities [ARIC] Study); M. Dramaix , G. deBacker , J-C. Wautrecht , M. Kornitzer (Belgian Physical Fitness Study); A. B. Newman , M. Cushman , K. Sutton-Tyrrell (Cardiovascular Health Study); F. G. R. Fowkes , A. J. Lee , J. F. Price (Edinburgh Artery Study); R. B. d’Agostino , J. M. Murabito (Framingham Offspring Study); P. E. Norman , K. Jamrozik (Health in Men Study); J. D. Curb , K. H. Masaki , B. L. Rodríguez (Honolulu Heart Program); J. M. Dekker , L. M. Bouter , R. J. Heine , G. Nijpels , C. D. A. Stehouwer (Hoorn Study); L. Ferrucci , M. M. McDermott (InCHIANTI Study); H. E. Stoffers , J. D. Hooi , J. A. Knottnerus (Limburg PAOD Study); M. Ogren , B. Hedblad (Men Born in 1914 Study); J. C. Witteman , M. M. B. Breteler , M. G. M. Hunink , A. Hofman (Rotterdam Study); M. H. Criqui , R. D. Langer , A. Fronek (San Diego Study); W. R. Hiatt , R. Hamman (San Luis Valley Diabetes Study); H. E. Resnick (Strong Heart Study); J. Guralnik , M. M. McDermott (Women’s Health and Aging Study).
Roberto Sánchez Torre el 9 Julio 2008
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Siguiendo el mismo tenero del artículo previo, envío dos artículos nuevos para su publicación, uno de a mediados del mes pasado, publicado en la revista Lancet, en él se analiza el papel de los lípidos, apolipoproteínas y lipoproteínas como marcadores para el riesgo de enfermedades cardiovasculares. Para ello se realizó un estudio de casos y controles en 52 países, incluido México, les dejo el resumen para que lo conozcan:
