Dr. José Cabezas Cerrato Departamento de Medicina (USC) · 2015-11-10 · Hospital Clínico...
Transcript of Dr. José Cabezas Cerrato Departamento de Medicina (USC) · 2015-11-10 · Hospital Clínico...
Hospital Clínico Universitario de SantiagoHospital Clínico Universitario de Santiago
Disfunción autonómica cardiovascular, riesgo cardiovascular estimado y variabilidad circadina de la presión arterial
Dr. José Cabezas Cerrato
Departamento de Medicina (USC)
Manifestaciones clínicas atribuidas a la NAC
• Disminución de la arritmia respiratoria.
• Taquicardia en reposo.
• Incompleta recuperación de la frecuencia cardiaca (FC) post-ejercicio.
• Disminución o falta de respuesta de la FC y de la PA durante elejercicio.
• Hipotensión ortostática (frecuentemente con HTA en decúbito).
• Hipotensión ortostática postprandial.
• Pérdida de la variabilidad circadiana de la PA.
• Incremento del RCV.
• Inestabilidad eléctrica miocárdica.
• Se asocia a una mayor mortalidad cardiovascular.
Manifestaciones menos frecuentes de la HO
• Hipoperfusión muscular:
• Dolor suboccipital y en escaleno (distribución “en percha”).
• Dolor lumbosacro y en glúteos.
• Manifestaciones que remedan el “robo de la subclavia”.
• Hipoperfusión renal: Oliguria.
• Hipoperfusión de la médula espinal:
• Claudicación.
• Ataxia.
CAN and silentmyocardial ischemia
Diabetes Care 26:1553-1579, 2003
Technical ReviewDiabetic Autonomic
NeuropathyA. Vinik, R. E. Maser, B.
D. Mitchell, and Roy Freeman.
Diabetes Care 26:1553-1579, 2003
Technical ReviewDiabetic Autonomic
NeuropathyA. Vinik, R. E. Maser, B.
D. Mitchell, and Roy Freeman.
DCAN and Mortality
Manifestaciones clínicas atribuidas a la NAC
• Pérdida de la variabilidad circadiana de la PA.
• Patrón no-dipper y su relación:
• Con la disfunción autonómica.
• Con el riesgo cardiovascular.
CARACTER N: 101 % X ± DE
HMEdadIMCCC, H => 94cm.CC, M => 80cm.CC => 94-80cmSP + OBSP-II + OB
5942
4333767963
5843
73/H79/M75/n7862
47±1228 ± 1.4
DM-1DM-2A1C %Evol años
4259
4258
8 ±1.412±8
Características principales de la muestra estudiada-I
Características principales de la muestra estudiada-II
CARACTER n:101 %
MicroAlbMDRD4V < 60HTA:No-dippersFumadores
1715504617
1715504517
SM (IDF)RCV-CI-UK-Fram, 10aRCV-ACV-UK, 10 añosCI > 10ACV > 4
53100814838
5399804838
TAU => 1TAU => 2
5037
5037
Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.
Mean = 0.23Mean + 2 SD
Mean - 2 SD
-20
-15
-10
-5
0
5
10
15
20
80 100 120 140 160 180 200
Diff
eren
ce(a
llda
ta -
data
sam
pled
ever
yho
ur)
Average systolic blood pressure (mm Hg)
PAS - Media de 24 horas
Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.
Mean = -0.28
Mean + 2 SD
Mean - 2 SD
-20
-15
-10
-5
0
5
10
15
20
80 100 120 140 160 180 200
Diff
eren
ce(a
llda
ta -
data
sam
pled
ever
y2
hour
s)
Average systolic blood pressure (mm Hg)
PAS - Media de 24 horas
Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.
Mean = -0.79
Mean + 2 SD
Mean - 2 SD
-20
-15
-10
-5
0
5
10
15
20
80 100 120 140 160 180 200
Diff
eren
ce(a
llda
ta -
data
sam
pled
ever
y3
hour
s)
Average systolic blood pressure (mm Hg)
PAS - Media de 24 horas
Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.
Mean = -0.85
Mean + 2 SD
Mean - 2 SD
-20
-15
-10
-5
0
5
10
15
20
80 100 120 140 160 180 200
Diff
eren
ce(a
llda
ta -
data
sam
pled
the
first
24 h
ours
)
Average systolic blood pressure (mm Hg)
PAS - Media de 24 horas
.
100
105
110
115
120
125
130
Diurnal mean Nocturnal mean 24-hour mean
G, 0G, 1
SBP
(mm
Hg)
SBP in diabetic patients without (G, 0) or with at least one positive testof autonomic dysfunction (G, 1)
p=0.140p=0.031p=0.253
0.00 4.00 8.00 12.00 16.00 20.00 24.00
TIME (HOURS AFTER AWAKENING)
102
107
112
117
122
127
0
-0° -60° -120° -180° -240° -300° -0°
PHASE (360° = 24 HOURS)
MESOR=116.04
0
00 0
0 0 0
0
0
00
0
MESOR=119.25
1
1
11 1
1 1
1
1
11
1
* *
Circadian pattern of systolic blood pressure in diabetic patientswithout (G, 0) or at least one positive test of autonomic dysfunction (G, 1)
SYST
OL
IC B
LO
OD
PR
ESS
UR
E (m
mH
g)
Comparison p-value for of:
MESOR 0.124Amplitude 0.348
Orthophase 0.342
.
50
55
60
65
70
75
80
Diurnal mean Nocturnal mean 24-hour mean
G, 0G, 1
DB
P(m
mH
g)DBP in diabetic patients without (G, 0) or with at leastone positive test (G, 1) of autonomic dysfunction
p=0.013p=0.334p=0.009
0.00 4.00 8.00 12.00 16.00 20.00 24.00
TIME (HOURS AFTER AWAKENING)
59
63
67
71
75
79
0
-0° -60° -120° -180° -240° -300° -0°
PHASE (360° = 24 HOURS)
MESOR=70.79
0
0 00 0 0
0
0
0
00
0
MESOR=67.44
1
1
1
1 11 1
1
1
11
1
* * * * * * *
Circadian pattern of diastolic blood pressure in diabetic patientswithout (G, 0) or with at least one positive test of autonomic dysfunction (G, 1)
DIA
STO
LIC
BLO
OD
PRES
SUR
E (m
mH
g)
p-value for comparison of:
MESOR 0.024
Amplitude 0.048
Orthophase 0.108
.
40
43
46
49
52
55
Diurnal mean Nocturnal mean 24-hour mean
G 0G, 1
PP(m
mH
g)
PP in diabetic patients without (G, 0) or with at least one positive testof autonomic dysfunction (G, 1)
p<0.001p<0.001p<0.001
0.00 4.00 8.00 12.00 16.00 20.00 24.00
Time (hours after awakening)
42.5
45.0
47.5
50.0
52.5
55.0
0.0
-0° -60° -120° -180° -240° -300° -0°
PHASE (360° = 24 HORAS)
MESOR=45.32
00
00
00
0
00
0
00
1
1
1
1 1
1 1 1
1
11
1
* * * * * * * * * * * *
Circadian pattern of pulse pressure in diabetic patients without (G, 0)or with at least one positive test of autonomic dysfunction (G,1)
PULS
E PR
ESSU
RE
(mm
Hg)
p- value for comparison of:MESOR <0.001Amplitude 0.852Orthophase 0.200
100
105
110
115
120
125
130
Diurnal mean Nocturnal mean 24-hour mean
CHD < 10CHD > 10
SBP
(mm
Hg)
SBP in diabetic patients divided according to risk of coronary heart.
disease (CHD)
p<0.001p=0.002p=0.002
.
50
55
60
65
70
75
80
Diurnal mean Nocturnal mean 24-hour mean
CHD <10CHD > 10
DB
P(m
mH
g)DBP in diabetic patients divided according to risk of coronary heart
disease (CHD)
P=0.747P=0.411P=0.943
.
40
43
46
49
52
55
Diurnal mean Nocturnal mean 24-hour mean
CHD < 10
CHD > 10
PP(m
mH
g)PP in diabetic patients divided according to risk of coronary heart
disease (CHD)
p<0.001p<0.001p<0.001
.
100
105
110
115
120
125
130
Diurnal mean Nocturnal mean 24-hour mean
Risk < 4Risk > 4
SBP
(mm
Hg)
SBP in diabetic patients divided according to risk of stroke
p=0.036p=0.011p=0.083
50
55
60
65
70
75
80
Diurnal mean Nocturnal mean 24-hour mean
Risk < 4Risk > 4
DB
P(m
mH
g)DBP in diabetic patients divided according to risk of stroke
p=0.006p=0.092p=0.007
.
40
44
48
52
56
Diurnal mean Nocturnal mean 24-hour mean
Risk < 4Risk > 4
PP
(mm
Hg)
PP in diabetic patients divided according to risk of stroke
p<0.001p<0.001p<0.001
Dos conclusiones mayores se derivan de esta investigación
• La disfunción autonómica no es la causa, ni tampoco parece ser un factor mayor implicado en la génesis del patrón No-Dipper de la PA en la DM.
• La disfunción autonómica en la DM se relaciona con una PP significativamente elevada, y ésta a su vez, con un elevado riesgo de CI y de ACV.