Nursingul pacientului

vartnic si HTA
Imbatranirea vasculara
Dr Mircea Iurciuc
The Guardian 2013
THOMSON
REUTERS
London - ESC Congress 31aug 2015
London 31 aug 2015 - ESC Congress
 Normal Arterial Function:
Basic Physiology
• The arterial tree has 2 functions
– first, to deliver blood from the left ventricle (LV) to
capillaries of bodily organs and tissues according to
their need - ‘the conduit function’
– second, to cushion the pulsations generated by the
heart; they behave as a ‘windkessel’ (hydraulic filter)
to dampen blood flow and pressure oscillations
caused by the intermittent character of the LV
ejection ensuring peripheral organ perfusion at
steady flow and pressure - so that capillary blood
flow is almost continuous - ‘cushioning or
dampening function’

• Safar M.E., O’Rourke M.F.; Arterial Stiffness in Hypertension. Handbook of Hypertension. 23. Edinburgh: Elsevier; 2006.
 Subclinical
atherosclerosis
Sublinical
organ damage
From: Mechanical Factors in Arterial Aging: A Clinical Perspective

J Am Coll Cardiol. 2007;50(1):1-13. doi:10.1016/j.jacc.2006.12.050

Figure Legend:
Cartoon of Young and Old Human Aorta
Schematic diagram of the aorta section in a young (left) and old (right) human, with inset (below each) the components of the aortic
wall. The wall of the older human is disorganized as a consequence of fraying and fracture of the elastic lamellae (yellow) and loss
of muscle attachments (red), together with increase in collagen fibers (black) and mucoid material (green), and with foci of
“medionecrosis.” Drawn by O’Rourke CM, after Glagov S. Personal communication, 1994.

Date of download: 8/18/2015 Copyright © The American College of Cardiology. All rights reserved.
Aorta Muscular artery

Arteriola
elastina
 Mecanisms of arterail aging
 Increased migration and proliferation of vascular
smooth muscle cell to intima
 Increase in collagen content and decrease in elastin
 The phenomenon of "fatigue" elastin
– Increase amplitude PP + HR increase frecvence
 Genes which induce the formation of
metalloproteinase
 Homocysteine (increases with age)
 Reduced availability of NO
 Oxidative stress, inflammation
 Genetic Programming - telomeres
– Shorten time with cell division
ESC – Congress 2009 - J Lekakis (Haidari, Athens, GR)
European Heart Journal (2010) 31, 2338–2350
 Scorul de calciu
 marker indirect de încărcare aterosclerotică a arterelor
coronare
 Motivarea subiectului asimptomatic de a adera la
recomandările privind SCHIMBAREA STILULUI DE
VIAŢĂ
 ACC/AHA NU recomandă screeningul populaţional al scorului
de calciu
 Cel mai folosit algoritm este scorul Agatston
 Subiecţii la RISC MEDIU pot fi consideraţi CANDIDAŢI la
determinarea scorului de calciu
scor Framingham 6-20%

 Interpretare: 1 = 131 – 199 risc mic

2 = 200 – 299 risc moderat
3 = 300 – 399 risc intermediar
4 ≥ 400 risc mare
 Scorul arterial specific = suma scorurilor lezionale pentru artera
analizată
 Scorul total = suma scorurilor ACD, trunchi ACS, ADA, ACx
Greenland P. Circulation 2000;101:e16-e22
IMT measurement according to Mannheim
consensus.
1: thickness > 1.5 mm; 2: lumen encroaching >0.5 mm;
TRATAMENT
 Metode pentru a imbunatatii
aderenta pacientilor la tratament
 Informare
 Motivare
 Automonitorizare
 Autoevaluare si autodozarea medicatiei
 Simplificarea medicatiei (polipil)
 Aducerea aminte a tratamentului
 Telemetrie
 Implicarea familiei/anturaj
23
 Coupling between structural and
functional changes

Haemodynamic forces and plaque vulnerability - N. Amabile (Paris FR) ESC Congress London 2015
 Elasticitatea
Proprietate a unor corpuri de a-și reveni la forma inițială după ce au
fost deformate.

E = (L-l) / (G-g)
l
 Young
L 1808
 Poiseuille
g 1840
 Moens
1878
 Korteweg
G 1878
 Modules and Indexes of
elasticity / stiffness
 Distensibility index ∆D/∆P*D (mmHg-1)
 Arterial compliance ∆D/∆P (cm/mmHg)
 The volumetric elastic modules ∆P(∆V/V) (mmHg)
 The simple elastic modules ∆P(D/∆D) (mmHg)
 The Young elastic modules ∆P * D/(∆D*h) (mmHg
cm)
 Augumententation index / pressure (mmHg or %from
PP)
 Characteristic Impedance ∆P/∆V (mmHg/cm3)
 Pulsatility Index IP=Vmax-Vmin/Vmed
 Beta stiffness index β = ln (Ps/Pd)/[(Ds – Dd)/Dd]
 Elastic module epsilon = (Ps – Pd)/[(Ds – Dd)/Dd
 Elasticity index of the large artery ∆V/∆P cm3/mmHg
 Schematic illustration of the pressure wave transmission along the arterial system.

Gerard M. London, and Bruno Pannier Nephrol. Dial.

Transplant. 2010;25:3815-3823

© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights
reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
 Aortic Stiffness
 Increase with pressure
 The isobaric concept of arterial stiffness
 Beta stiffness index
 Elastic Young Modulus
 PWV increase with age
5,5 m/s la 10 y
11 m/s la 80 y
With a steep increase at about 55 y

Congresul de Prehipertensiune Viena 2011

 Increasing PWVcf
corelaters with CV mortality

Stiffness of Capacitive and Conduit Arteries – LONDON 2005

Bruno Pannier, Alain P. Guérin, Sylvain J. Marchais, Michel E. Safar and Gérard M.
N = 305, 70 months follow up, Hypertension 2005;45:596
 Determinants of pulse wave velocity in healthy
people and in the presence of cardiovascular risk
factors: ‘establishing normal and reference values’

European Heart Journal (2010) 31, 2338–2350

Increasing arterial stiffness

Hypertension 2001;38:434
 Time course for the development of arterial stiffness
Isobaric stiffness

ADAM aggressive decrease of atherosclerosis modifiers

Nilsson P M et al. Hypertension 2009;54:3-10

Copyright © American Heart Association
CAVI
CAVI - Cardio-ankle vascular index
 Heterogeneity of elastic properties along the arterial tree.

Stéphane Laurent, and Pierre Boutouyrie

Circulation Research. 2015;116:1007-1021

Copyright © American Heart Association, Inc. All rights reserved.

Other issues which can be correlated with
arterial stiffness
 Evaluating the diurnal / nocturnal BP profile
• Dipper / Nondipper / Extreme dipper / Reversed dipper
• Sustained / Isolated nocturnal / Isolated diurnal /
Normotension
 MBPS – Morning Blood Pressure Surge
 AASI – Ambulatory Arterial Stiffness Index
 Smoothness index – SI
 BP Variability
 “Entropia tensionala”
 “Indexul de dispersie a valorilor tensionale”
 “Incarcarea tensionala”
 Arterial stiffness and BP variability

Mancia G Hypertension 2012;60:512-517

Copyright © American Heart Association

 Noi metode imagistice pentru
vizualizarea placii de aterom
 OCT: Tomografia prin coerenta optica ce arata
microstructura peretelui arterial, compozitia
placii (lipide, cibroza, calciu), masurarea
riguroasa a capsulei fibroase
 NIRS: near-infrared spectroscopy
 MRI: imagini prin rezonanata magneticace arata
fibroza, continutul lipidic si poate studia evolutiv
placa
 PET: tomografia prin emisie de pozitroni ce
arata inflamatia si placa vulnerabila
 PET-CT si PET-MRI ce rata si continutul in
macrofage cu rol esential in formarea placii de
Histologie Palpography
virtuala

Elastograma
Modulograma
 Clasificarea leziunilor
Histologia virtuala

1. Fibrotic

2. Fibrocalcificate

3. Ingrosare patologica intimala (PIT)

4. Capison fibros ingrosat (ThCFA)

5. Capison subtire fibroatheroma (VH-TCFA)

(risc inalt – placa vulnerabila)
From: Intravascular Palpography for Vulnerable Plaque Assessment
J Am Coll Cardiol. 2006;47(8s1):C86-C91. doi:10.1016/j.jacc.2006.01.035

Principle of the intravascular elastography measurement

procedure. An intravascular ultrasound (IVUS) image is
acquired with a low (P2) and a high (P1) intraluminal
pressure.
Using cross-correlation analysis on the high-frequency
radiofrequency data, the radial strain in the tissue is
determined. This information is superimposed on the IVUS
image. In this example, an eccentric soft lesion is visible
between the 6- and 12-o’clock positions in the elastogram
where it cannot be identified from the IVUS image.
Date of download: Copyright © The American College of Cardiology.
4/26/2015 All rights reserved.
Intravascular Palpography for Vulnerable Plaque Assessment

In vivo intravascular ultrasound image and palpogram of a human coronary artery. The elastogram
reveals that the plaque has soft edges with adjacent hard (calcified) tissue. Plaque deformability was
scored according to the Rotterdam
Date of download:
classification (ROC), in which ROC I and IV indicate low (0% to
Copyright © The American College of Cardiology.
0.6%) and very high (>1.2%) deformation, respectively,
4/26/2015 by strain.
All rights reserved.
Alternatives

• Combined VH IVUS with OCT

• VH-TCFA thin-cap fibroatheroma
• Combined imaging system IVUS-
NIRS
From: Hybrid Intravascular Imaging: Current Applications and Prospective Potential in the Study of Coronary
Atherosclerosis

J Am Coll Cardiol. 2013;61(13):1369-1378. doi:10.1016/j.jacc.2012.10.057

Fusion of IVUS, NIRS Imaging, and CTCA

Fusion of computed tomographic coronary angiography (CTCA) (A), intravascular
ultrasound (IVUS), and near-infrared spectroscopy (NIRS) imaging (B). The obtained
model (C) allows the assessment of vessel morphology and of plaque distribution and
identification of the location of lipid-rich plaques. (D) Shear stress distribution on the
luminal surface portrayed inCopyright
Date of download: a color coded
© The map.
American College of Cardiology.
5/1/2015 All rights reserved.
 Regresia placii de aterom?
 Studii pentru regresia placii de aterom:
– REVERSAL Nissen SE et al. JAMA.2004;
291:1071e80
– ASTEROID scaderea volumului cu 6.8%
 Placa vulnerabila
– nu ale volum mare.
– Produce stenoze uneori < 50%
– Saraca in celule musculare
– Capsula fibroasa subtire
– Vasa vasorum dezvoltata
– Studii angiografice releva reducerea dupa un
tratament intens cu doar 7% si numai placa de