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Causes of death in Europe

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Presentation on theme: "Causes of death in Europe"— Presentation transcript:

1 Atherosclerosis Coronary heart disease Angina pectoris Myocardial infarction

2 Causes of death in Europe
men coronary heart disease (MI) 21% trauma and poisoning 12% stroke 11% pulmonary carcinoma 6% carcinomas in GIT % women coronary heart disease 21% stroke 18% other CVS diseases 15% trauma and poisoning 5% breast carcinoma %

3 Atherosclerosis syndrome affecting large and medium-sized arteries
artery wall thickenings – lipid infiltration - atheroma creation chronic inflammatory response in the walls of arteries hardening of the artery wall (loss of elasticity) Result - insufficient blood supply to the heart – myocardial infarction (heart attack) to the brain – stroke to the legs – claudicatio

4 Tunica intima Endothelial cells Tunica media Smooth muscle cells Tunica adventicia

5 Atherosclerosis typ spravnia A, selen, mg,

6 Atherosclerotic plague
Thrombus Endothelial cells Rupture of fibrous cap Platellets Smooth muscles cells Foam cells Lipid core

7 Stages of atherosclerotic plaque development
Type I – isolated foam cells macrophages with a droplet of fat in intima Type II – fatty streaks foam cells layer Type III higher amount of lipids under the foam cells layer Type IV – atheroma lipid core, fibrous cap Type V more collagen and smooth muscle cells in fibrous cap Type VI atheroma with complications - thrombosis

8 typ spravnia A, selen, mg,

9 Coronary heart (artery) disease
result of the ateromatous plaques within the walls of the coronary arteries limitation of blood flow to the heart → ischaemia Result Angina pectoris Myocardial infarction

10 Coronary heart disease
coronary artery obstruction due to atherosclerosis lack of blood (oxygen) supply physical acitivy (emotional stress) activation of sympathicus  heart rate and contraction  demand after oxygen supply PAIN

11 Risk factors (CHD, IM) Basic biological Biochemical, classical
age, gender, family history (= genes) Biochemical, classical cholesterol, LDL-CH, TAG, ¯ HDL-CH, apoproteins, Lp(a), indexes Biochemical, new fibrinogen, homocysteine, ferritin small dense LDL, oxidized LDL Nutrition and life style too much fat, sugar, antioxidant and fiber deficiency SMOKING, SEDENTARY LIFE STYLE Diseases obesity, diabetes (IR!), hypertension, kidney failure Genetic RF LDL receptor (FH), apo E variants and many others typ spravnia A, selen, mg,

12 Basic biological factors
age men > 45 years women after menopause gender men > women

13 Obesity obesity hyperinsulinaemia dyslipidaemia central typ

14 Hypertension endothelium damage

15 Smoking nicotine effect on lipid metabolism vasoconstriction CO
carboxyhaemoglobin increased coagulation cascade activity

16 Endothel Intelligent interface between blood and vessel wall/tissues
1500 g, football field (1000 m2) Endocrine, paracrine and autocrine functions vessel tonus, coagulation, adhesion, cell replication Organ specificity, differences in arteries, capillaries a venes Dysfunction in hypertension, diabetes, dyslipidemia...

17 Lipoproteins

18 Cholesterol, free and esters with fatty acids
275 mmol in the body 50 mmol LP, GIT, liver 25 mmol fat tissue 90 mmol muscles & vessel wall 110 mmol nervous system 3 mmol/d exchange Cholesterol In: food and synthesis in cells (from CoA) Breakdown: no Out: bile (enterohepatal circuit); stool LDL cholesterol The normal level (3,1 – 3,9 mmol/l) is not normal for the endothel Newborns & atherosclerosis resistant animals only » 0,8 mmol/l

19 Triacylglycerols & fatty acids TAG & FFA
15 kg in nonobese subjects kJ; enough for 3 months Thermal isolation, fertility, body shape Intake & synthesis: 80 – 170 mmol/d Different fatty acids – saturated, unsaturated, polyunsaturated (eikosanoids), shorter and longer chain Rapid turnover dependent on diet and alcohol intake, breakdown through physical activity (FFA – minutes)

20 Lipoproteins water-soluble particles, that transport water-insoluble lipids in the blood lipids Free cholesterol Phospholipids Triacylglycerols Cholesterol esters proteins Apolipoproteins

21

22 Apoproteins

23 3 lipoprotein families (LP)
spherical or discoid particles synthesised in guts or liver Hydrophilic surface (phospholipids, cholesterol esters and apoproteins) Hydrophobic inner part (TAG, CH) Dynamic interaction with vessel wall and each other Chylomicrons Þ chylomicron remnants VLDL Þ IDL Þ LDL (heterogenous group) HDL nascent Þ HDL3 Û HDL2

24 Chylomicrons Enterocytes apoB48, others from HDL
TAG into fat and other tissues, LPL CH into liver (from bile and food) Peak 3 – 6 h after meal, t1/2 30 min, after 9 h Ø Remnants into liver through receptor cytotoxic and atherogenic

25 VLDL – LDL family Liver, endogeneous TAG, CH B100 and others
functions and metabolism similar to CHY VLDL t1/2 2 – 4 hod, transformation to IDL, LDL LDL has a slow turnover, can be modified – oxidation, glycation small dense LDL Receptor and scavenger receptor

26 LDL classes LDL class density, g/ml diameter, nm % of LDL I 1,025
27,5 – 26,0 3 II 1,028 26,0 – 25,5 16 III 1,034 25,5 – 24,2 50 IV 1,048 24,2 – 21,8 22 V > 1,048 < 21,8 9

27 Small dense LDL Lipoprotein(a) Oxidized LDL (oxLDL) small
easy transport to intima of vessels higher density higher TAG concentration easy oxidation Lipoprotein(a) LDL with apoproteine(a) – glykoprotein very similar to plasminogen higher risk of thrombosis Oxidized LDL (oxLDL) high atherogenity higher macrophage afinity x higher than to LDL

28 Reverse transport of cholesterol by HDL
Liver, enterocytes and fromCHY as nascent „disc“ Lot of apoproteins LCAT and CEPT lecitin-cholesterol acyltransferase, esterifies CH cholesterol ester transfer protein transprots CH-E from HDL into other LPs Takes out cholesterol from tissues, disc is filled to HDL3 Exchanges CH-E for TAG with other LPs transforms to HDL2 Binds through AI to specific receptor in liver

29 liver HDL HDL2 nascent HDL vessel tissues

30 Apolipoprotein E E3 = 112 Cys, 158 Arg E2 = 112 Arg, 158 Arg
3 allels - APOE2, APOE3, APOE4 APOE4 - high cholesterol and LDL-chol, high risk of complications of atherosclerosis E3 = 112 Cys, 158 Arg E2 = 112 Arg, 158 Arg E4 = 112 Cys, 158 Cys

31 Normal (desired) values
T-CH < 5,0 mmol/l 4,55 – 5,45 HDL-CH > 1,0 mmol/l 0,87 – 1,13 LDL-CH < 3,0 mmol/l 2,65 – 3,35 TAG < 2,0 mmol/l 1,70 – 2,30 INDEXES T-CH/HDL-CH < 5,0 NONHDL-CH < 3,8 LDL-CH/HDL-CH < 3,0 Klimov (T-CH – HDL-CH)/HDL-CH < 4,2 APO AI/APO B > 1,3 ???

32 Other laboratory methods
Special Apo B, Apo AI, Lp(a) homocysteine, coagulation and fibrinolytic factors. Very special LDL receptors Apo C, E, LPL, CETP, LCAT classes of LDL, HDL Yesterday total lipids, phospholipids, fatty acid esters elektrophoresis Tomorrow - genomics

33 Hyperlipoproteinemias

34 Classifications Fredrickson 1967, WHO 1970
I, IIa, IIb, III, IV, V, VI - partly history Therapeutical 1992, European task force CH, TAG, both Etiological – future primary and secondary DLP is not sufficient! most primary DLP are not exactly characterized

35 “Primary DLP” Familiar hypercholesterolemia (LDL rec.)
Familiar defect of ApoB100 (FDB) Polygenous hypercholesterolemia Polygeneous hypertriglcyceridemia Dysbetalipoproteinemia (IDL) Familiar type V hyperlipidemia

36 “Secondary DLP” Nutrition and lifestyle
including smoking, alcohol and micronutrient deficiency Obesity Diabetes mellitus type 2 usually, decompensated type 1 (BG 20 – extreme TAG) Kidney failure Liver disease Endocrine diseases – ß thyroid function Drugs Hormones – anticonception, gravidity, postmenopausal, anabolics

37 Familial hypercholesterolaemia
AD inherited defect of LDL receptor (> 300 mutations of LDLR) Symptoms increased LDL-chol concentration atherosclerosis (high risk of MI, homozygouts in decenium) LDL LDL receptor

38 Symptoms and signs xantelasma palpebrarum xantomas
arcus lipoides corneae atherosclerosis and CHD

39 Angina pectoris severe chest pain due to ischaemia of the heart muscle, due to obstruction of the coronary arteria Symptoms after exertion, emotional stress, in the rest chest pain (or discomfort) lasting several minutes referred pain to the arms, shoulders, neck, chin exacerbated by full stomach or cold temperature breathlessness, sweating, nausea pain relieved by nitroglycerin

40 Types of angina pectoris
Stable AP stable atherosclerotic plaque retrosternal pain precipitaded by activity (walking, running) no pain in rest 3 – 5 min referred pain to the arms, shoulders, back... Unstable AP „crescendo“ angina unstable atherosclerotic plaque at rest > 10 min. more serious symptoms Variant (Prinzmetal´s, vasospastic) AP caused by vasospasm unknown mechanism (dysfunction of endothelium?) atherosclerotic changes – not necessary at rest (at night, early morning)

41 Myocardial infarction
Acute myocardial infarction Heart attack Necrosis of the heart cells due to interruption of blood supply to the part of the heart Causes rupture of the ustable atherosclerotic plaque → trombosis coronary artery obstruction by the stable plaque

42 Signs and symptoms sudden chest pain radiating to the left arm, shoulder, neck, chin... pain not relieved by nitroglycerin anxiety nausea, vomiting, sweating dyspnea pale, cold skin cardiogenic shock symptoms arterial pressure decrease tachycardia sometimes silent ischaemia – without pain (e.g. diabetic neuropathy)

43 Pain left shoulder neck chest right shoulder epigastrium arm

44 ECG diagnosis T wave inverion ST segment elevation patological Q wave

45 Complication of MI dysrhythmias heart failure shock and hypotension
myocardial rupture valve defects embolisation pericarditis

46 Cardiac markers myoglobin (Mb) troponin I (TnI), T (TnT)
creatine kinase (CK) heart MB subtype (CK-MB) lactate dehydrogenase (LD) aspartate aminotranspherase (AST)

47 CK-MB myoglobin troponin I 0 1 2 3 4 5 6 7 14 serum concentration
time (days)

48 activity CK-MB AST LD time (days)

49 Complication of MI dysrhythmias heart failure shock and hypotension
myocardial rupture valve defects embolisation pericarditis


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