CCC

-
,


.

,

.

 CCC

40
,

()

N -200*220//
6,5-
5,2-5,7 5,8-

() :
(

40-45 , 55-60 )

( );
(

,
)

2.
2.
.

10 , .
(
,
,

,
.. )

3.

4.

5.
6.
7.
8.

 -

140 ..
/ 90
.. ,
.

40 .
.

55

65

> 6,5
/


(
65

55 )

(,

)
/
(105,6
176 /)

>176 /

Fast-food

,

IOTF/EASO Obesity in Europe Report 2002

 2025

50%
40%
, 2002

,
.

,
,


8 10

.


2
,
.

 4000 ,

, ,
.

,
.
(, ,
), ().
, ,
, ,
.
,
60
(,
).

 :

, .
.

,
, .
10-15
.

.


-
( );
,

(
,
, , )


Totalitatea tulburrilor cantitative i calitative ale
lipidelor plasmatice (C, TG, HDLc)
Prevalena >30%
Factor major de risc pentru ATS

Normalul lipidic:

CT <200 mg%
TG <150 mg%
HDLc 40-45 mg%
45-50 mg%

Clasificarea dislipidemiilor
n funcie de natura anomaliei
Hipercolesterolemii (HC)
Genetice (primare, familiale)

Secundare

HC familial
HC prin deficit de apoB100
HC poligenic

Hipotiroidism
Sindrom nefrotic
Colestaz

Hipertrigliceridemii (HTG
Genetice (primare, familiale)
Deficit de LPL
nesatisfctor,
Deficit de apo CII
uremie,
HTG familial
betablocante

Secundare
DZ controlat

sindrom nefrotic,
alcoolism, estrogeni,

Clasficarea n funcie de severitate

Hipercolesterolemii
uoare: 200-239 mg%
moderate: 240-299 mg%
severe: 300 mg%

Hipertrigliceridemii
de grani: 150-199 mg%
moderate: 200-399 mg%
severe: 400 mg%

Hiperlipidemii mixte
moderate:
severe:

C
200-299 mg%
300 mg%

TG
200-400 mg%
400 mg%





( )

 (
)

(1 -9)
: -

,
,

, ,





:
-, ,
.,


-
.

A-I

A-I

A-II
A-I, A-II = A-I, A-II;
= ; =

Clasificarea lipoproteinelor
Clasa

Coninut lipidic (%)*

TG
C
FL

Chilomicroni
VLDL
IDL
LDL
HDL
Lp(a)

80-95
55-80
20-50
5-15
5-10
5-15

2-7
5-15
20-40
40-50
15-25
40-50

*=diferena pn la 100% este reprezentat de Apo

3-9
10-20
15-25
20-25
20-30
20-25

Metabolismul lipoproteinelor
Alimente
Lumen
intestinal

TG

TG

Receptori LDL

Apo
B100

Colesterol
CE

AGL

Glicerol

LDL
Colesterol
HTGL

TG
Perete intestinal

TG

Apo
B48, CII,
CIII, E

TG

Chilo

CE

Colesterol

Apo
AI, AII

IDL
HDL

TG

Receptori
LDL

CE

Apo
B100, CII,
CIII, E

LPL

AGL

Receptori
LDL, LRP

Apo
B100, CII,
CIII, E

CE

LPL

TG

AGL
CE

VLDL
Apo
B48, CII,
CIII, E

TG

Receptori LDL
i LRP

TG

CE

Remn
AGL

AGL

Legend: TG=trigliceride; CE=colesterol esterificat; FL=fosfolipide; Apo=apolipoproteine; AGL=acizi

grai liberi; chilo=chilomicroni; remn=remnani; LPL=lipoproteinlipaza; TGL=hipertrigliceridlipaza.

()
() :
.

():
-
.

()
- ,

MTP

Exogenous Pathway

Endogenous Pathway

Bile acids and

Cholesterol

Dietary fat

ApoB -100

LDL

LDL-R

Liver
Intestine

Endogenous
Cholesterol

LDL-R

Extra Hepatic
Tissue

Dietary
Cholesterol

Remnant
Receptor

Chylomicrons

Remnants

ApoE C-II
B-48

VLDL

IDL

ApoE
B-48
ApoE C-II
B-100

HDL
ApoE
B-100

ApoA-I
A-II

Plasma LCAT
(lecithin cholesterol
acyl transferase

Lipoprotein lipase
Free fatty acids
Adipose tissue, muscle

Lipoprotein lipase
Free fatty acids
Adipose tissue, muscle


()

-

: ()

(., )

MTP
(Inhibitors)

( ) (/)
( )
5.17 / = 200 /
- 38.7

(12 )
- (/)
- (/)
- (/)
- 88.6
:
= - -/5

400 /



< 5.17 / =
5.17-6.19
=

> 6.20
=


()
< 2.58
2.58-3.33
3.34- 4.12
4.13-4.88
> 4.88

=
=
=
=
=


()
< 1.03 /

=
(

> 1.55 mmol/L

=
( )


- /
() - 88.6
:
< 150 /
-
150-199
-

200-499
-
> 500
-

(3 )

, ,
, ,
(Lupus)

/ -( )

/

,
Am J Cardiol 76:8A-20A, 1995

( , )

( , , , , )

Clasficarea n funcie de severitate

Hipercolesterolemii
uoare: 200-239 mg%
moderate: 240-299 mg%
severe: 300 mg%

Hipertrigliceridemii
de grani: 150-199 mg%
moderate: 200-499 mg%
severe: 500 mg%

Diagnostic
1. Tablou clinic
2. Aspectul serului sau plasmei

3. Dozarea CT, TG, HDLc

4. Calcularea LDLc
5. Alte metode (de cercetare)

1. Tablou clinic

Xantelasm

Arc cornean + xantelasm palpebral

Xantoame tuberoase

Xantoame tendinoase

Xantoame tendinoase

2. Aspectul serului
sau plasmei
Tub 1: plasm normal
Tub 2: HTG
Tub 3: plasma cu exces de VLDL
i chilomicroni (inel cremos la
suprafa)

3. Dozarea lipidelor

CT:

>200 mg%

TG:

>150 mg%

HDLc:

<40 mg%
<45 mg%

4. Calculul LDLc/non HDLc

Formula lui Friedewald
TG <400 mg%
LDLc = CT HDLc TG/5 (mg%)
Calculul non-HDLc
TG >400 mg%
Non-HDLc = CT HDLc


Fredrickson

++++

LDL

++

+++

LDL VLDL

++

++

+++

IDL

++

+++

+++

VLDL

++

VLDL X

++++

Plci de aterom

Factori de risc adiionali

Vrsta (brbai >45; femei >55 sau
menopauz prematur fr tratament de
substituie estrogenic)
Istoric familial de boal coronarian
precoce
Fumat
Hipertensiune arterial (>140/90 mmHg
sau tratament antihipertensiv)
HDL sczut (<35 mg%)
Diabet zaharat

 -

, ,
,
,

.
( ..)

(NCEP ATR III)

, ()

94
80

90th
90th

150 / (1,69 /)

110 / (1,24 /)

40 / (1,04 /)
50 / (1,29 /)

40 / (1,04 /)
40 / (1,04 /)

130/85 ...

90th

100 %
(5,6 /)

100 %
(5,6 /)


:
/ + + +
+

Tratament
I.Schimbarea stilului de viata
a. activitatea fizica regulata
- reduce nivelul VLDL
- creste HDL
- scade LDL
- scade valorile tensionale
- scade rezistenta la insulina
b. controlul greutatii
- normalizarea IMC normalizarea TG si cresterea HDL

c. dieta
- reducerea ingestiei de grasimi saturate <7% din calorii
- reducerea colesterolului <200 mg/zi
- cresterea moderata a uleiurilor mono- si polinesaturate
- cresterea glucidelor complexe, fibrelor alimentare si legumelor
Daca dupa 12 sapt tabloul lipidic nu se normalizeaza
tratament medicamentos

Mijloace pentru scderea i

meninerea greutii
Modificarea stilului de via
regim alimentar
activitate fizic
modificarea comportamentului
alimentar

Farmacoterapie
Intervenii chirurgicale pentru
scderea greutii (chirurgia
bariatric)

Regimul alimentar
Hipocaloric
Dietele VLCD (<800 kcal/24 de ore, dar nu de zero calorii) - cu
1,5-2,5 kg/sptmn
1200 kcal/24 de ore - de 0,5-0,6 kg/sptmn
Dieta ad-libitum, hipolipidic

Hipoglucidic
120-150 g G /zi- din fructe, legume i, n cantitate , din pine i
din cartofi

Hipolipidic
maximum 40 g L (0,7-0,8 g/kg corp/zi), n special nesaturate.

Normoproteic
1 g P /kg corp/zi - din lactate degresate, carne slab i, n special,
din pete

Obiectivele reducerii LDL

Tinta LDL

Cardiopatia ischemica si echivalenti

<100

Factori de risc multiplii(2+)

<130

0-1 factori de risc

<160

Factori majori de risc care modifica tinta LDL

- fumatori
- HTA
- HDL<40 mg/dl
- istoric familial de CI premature (CI la rudele masc de gr I <55 ani, CI
la rudele feminine de gr I<65 ani

- varsta (barbati >45 ani;femei >55 ani)

- diabetul e condiderat ca echivalent de risc al CI

inte terapeutice
Categorie
Risc CV nalt:
-boal CV
-DZ tip 2
-DZ tip 1 + albuminurie
-SCORE 5
Risc CV sczut:
-SCORE <5

CT

LDLc

<175 mg%
(<155 mg%)

<100 mg%
(<80 mg%)

<190 mg%

<115 mg%

Mijloace terapeutice
Dieta
Medicaia hipolipemiant
1. Fibrai

2. Statine ( ezetimide)
3. Alte (rini chelatoare de acizi biliari, acid
nicotinic)

Dieta
Nutrient

Treapta 1

Treapta 2

Lipide
totale

<30% din calorii

<30% din calorii

Grsimi
saturate

<10% din calorii

<7% din calorii

Proteine

10-20% din calorii

10-20% din calorii

Colesterol

<300 mg/zi

<200 mg/zi

Glucide

50-60% din calorii

50-60% din calorii

Fibrai
Doza (mg/zi)
fenofibrat (Lipanthyl supra 160 mg/cp)

160 mg

bezafibrat (Regadrin 200 mg/cp)

600-1200 mg

ciprofibrat (Lipanor 100 mg/cps)

100 mg



,


-
HDL

PPAR
(peroxisome proliferator
activated receptor)

:
1. -
2.

3.
=>
VLDL
4. HDL

Niacin
( Vit B3 )
, ,
VLDL, LDL HDL
1000-2000



flush
Aspirin.

Ezetimibe

Statine
Doza (mg/zi)
Atorvastatin

10-80

Simvastatin

10-80

Pravastatin

10-40

Lovastatin

20-80

Fluvastatin

20-80

Rosuvastatin

10-40

LDL,



HDL.
-

a b.

Tratamentul medicamentos
Statinele
- cea mai eficienta clasa de medicamente
- inhiba HMCo reductaza

scad colesterolul total si LDL-col

scad moderat TG
crestere modesta a HDL-col
- ameliorarea disfunctiei endoteliale
- stabilizarea placii aterosclerotice
- efect antiinflamator
- efect antitrombotic
Simvastastina 10-40mg/zi
Fluvastatina 20-40 mg/zi
Atorvastatina 10-20 mg/zi

RA:miopatie, cresterea enzimelor hepatice

- indicatie la toti pacientii cu leziuni arteriale
- scad incidenta CI,AVC, arteriopatii periferice
- in preventia secundara- scad necesitatea procedurilor de revascularizatie

Ezetimibe
Inhib selectiv absorbia colesterolului

n intestinul subire
LDL compensator sinteza
endogen a colesterolului
Necesit asociere cu o statin

Strategia terapeutic
SCORE 5%

BCV

SCORE <5%

DZ tip 2
DZ tip
1+albuminurie

MSV

MSV
Tratarea tuturor FR

Reevaluare dup 3
luni

Statine pt HC
inte: CT <175 (155)
mg%
LDLc <100 (80)
mg%

CT <190 mg%
SCORE
5%

LDLc <115
mg%
SCORE <5%

MSV
inte: CT <190 mg%
LDLc <115

mg%
Dispensarizare

200
/ (5,2 /)
2-
- 160 / (4
/)

()
,
130
/ (3,4 /)

Applying Classification of Recommendations

and Level of Evidence
Class I

Class IIa

Class IIb

Class III

Benefit >>> Risk

Benefit >> Risk

Additional studies with
focused objectives
needed

Benefit Risk
Additional studies with
broad objectives needed;
Additional registry data
would be helpful

Risk Benefit
No additional studies
needed

Procedure/ Treatment
SHOULD be
performed/
administered

IT IS REASONABLE to
perform
procedure/administer
treatment

Procedure/Treatment
MAY BE CONSIDERED

Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY
BE HARMFUL

Level of Evidence:

Level A:

Data derived from multiple randomized clinical trials or meta-analyses

Multiple populations evaluated;

Level B:

Data derived from a single randomized trial or nonrandomized studies

Limited populations evaluated

Level C:

Only consensus of experts opinion, case studies, or standard of care

Very limited populations evaluated



, ;
,
.
-


:
22% 30%,
22%,
28%.

,
2 ,
- .

,
, 10
5%

2,5 /

2,5 /

3,0 /

2
10-

5%

3,0 /

3,0 /

3,5 /

01

3,0 /

3,5 /

4,0 /

,
,
.
23 18
. ,
, ,
;
6 .


.

.

, .

,
,

.
400-500
.

.
,
140/90

..

.

:
,
, -
;
;
, (

).


75 /, 100 /
325 .
.
,

,
.. .
,

,
,
1 612 .,
(, ,
, ,
),
.

(
,
,

)
-
,
.

-
-
-
-
-

-
-
(,
-
)

,

-

()
,
;
()
;

140/90 ...;
;

30-40
3
,