無癥狀人群心血管病風(fēng)險的評估

無癥狀人群心血管病風(fēng)險的評估無癥狀人群心血管病風(fēng)險的評估第1頁年中國衛(wèi)生統(tǒng)計提要心腦血管疾病是我國首位死亡原因08年我國疾病死亡病因疾病死亡率組成比（%）50403020100城市農(nóng)村心臟病腦血管病無癥狀人群心血管病風(fēng)險的評估第2頁RiskfactorsforthedevelopmentofatheroscleroticdiseaseApproximately37%ofAmericanadultsreportedhaving2riskfactorsforCVD.90%ofpatientswithcoronaryheartdiseasehaveatleast1atheroscleroticriskfactor.ApproximatelyhalfofallcoronarydeathsarenotprecededbycardiacsymptomsordiagnosesAReportoftheAmericanCollegeofCardiologyACCF/AHAGuidelineforAssessmentofCardiovascularRiskinAsymptomaticAdults無癥狀人群心血管病風(fēng)險的評估第3頁一級預(yù)防

是降低心腦血管疾病危害根本辦法腦卒中發(fā)生率冠心病發(fā)生率冠心病死亡率83~89%78~85%65~73%70~76%腦卒中死亡率Lancet,362:271改進(jìn)高危原因顯著降低了心腦血管事件發(fā)生無癥狀人群心血管病風(fēng)險的評估第4頁我國人群心血管危險原因控制現(xiàn)況高血壓患者1．8億人吸煙者3．5億人，被動吸煙者5．4億人血脂異?；颊?．6億人糖尿病患者4000萬人肥胖患者6000萬人，超重者2億人當(dāng)前每年新增高血壓或血脂異常人數(shù)1000萬人無癥狀人群心血管病風(fēng)險的評估第5頁我國人群心血管危險原因控制不利年調(diào)查資料顯示，全國血壓控制率僅為6．1％年:血脂控制率僅為50％，高危、極高危人群僅為49％和38％年糖尿病調(diào)查表明，糖尿病患者糖化血紅蛋白(HbAIc)達(dá)標(biāo)(<6．5％)僅占25％吸煙者中只有26％人希望戒煙，戒煙成功率僅為11．5％無癥狀人群心血管病風(fēng)險的評估第6頁心血管疾病一級預(yù)防中國教授共識

——危險原因評定方法FraminghamSCOREPROCAM(Men)Reynolds(Women)Reynolds(Men)中國缺血性心血管病危險評定模型(KNOWyourrisk)無癥狀人群心血管病風(fēng)險的評估第7頁心血管病危險原因傳統(tǒng)危險原因：年紀(jì)、性別、種族、家族史、高膽固醇血癥、吸煙、糖尿病、高血壓、腹型肥胖、缺乏運動、飲食缺乏蔬菜水果、精神擔(dān)心“新”危險原因：

C反應(yīng)蛋白、載脂蛋白a、纖維蛋白原、同型半胱氨酸、尿酸無癥狀人群心血管病風(fēng)險的評估第8頁RiskfactorsforthedevelopmentofatheroscleroticdiseaseCVDwasmentionedonthedeathcertificatesof56%ofdecedentsin.Itwaslistedastheunderlyingcauseofdeathin35.3%(864,480)ofalldeaths(2,448,017)inor1ofevery2.8deathsintheU.S.Ineveryyearsince1900(except1918),CVDaccountedformoredeathsthananyothermajorcauseofdeathintheUnitedStates(6).ItisestimatedthatifallformsofmajorCVDwereeliminated,lifeexpectancywouldrisebyalmost7yearsAReportoftheAmericanCollegeofCardiologyACCF/AHAGuidelineforAssessmentofCardiovascularRiskinAsymptomaticAdults無癥狀人群心血管病風(fēng)險的評估第9頁Assessment

ofCardiovascularRisk

CLASSIGlobalriskscores(suchastheFraminghamRiskScore)thatusemultipletraditionalcardiovascularriskfactorsshouldbeobtainedforriskassessmentinallasymptomaticadultswithoutaclinicalhistoryofCHD.Thesescoresareusefulforcombiningindividualriskfactormeasurementsintoasinglequantitativeesti-mateofriskthatcanbeusedtotargetpreventiveinterventions.(LevelofEvidence:B)無癥狀人群心血管病風(fēng)險的評估第10頁FamilyHistoryCLASSIFamilyhistoryofatherothromboticCVDshouldbeobtainedforcardiovascularriskassessmentinallasymptomaticadults.(LevelofEvidence:B)CLASSIII:NOBENEFITGenotypetestingforCHDriskassessmentinasymptomaticadultsisnotrecommended.(LevelofEvidence:B)AReportoftheAmericanCollegeofCardiologyACCF/AHAGuidelineforAssessmentofCardiovascularRiskinAsymptomaticAdults無癥狀人群心血管病風(fēng)險的評估第11頁

OtherCirculatingBloodMarkersand

AssociatedConditionsCLASSIII:MeasurementofnatriureticpeptidesisnotrecommendedforCHDriskassessmentinasymptomaticadults.(LevelofEvidence:B)CLASSIIaInmen50yearsofageorolderorwomen60yearsofageorolderwithLDLcholesterollessthan130mg/dL;notonlipid-lowering,hormonereplacement,orimmunosuppressanttherapy;withoutclinicalCHD,diabetes,chronickidneydisease,severeinflammatoryconditions,orcontraindicationstostatins,measurementofCRPcanbeusefulintheselectionofpatientsforstatintherapy.(LevelofEvidence:B)無癥狀人群心血管病風(fēng)險的評估第12頁HemoglobinA1C(HbA1C)CLASSIIb1.MeasurementofhemoglobinA1C(HbA1C)maybereasonableforcardiovascularriskassessmentinasymptomaticadultswithoutadiagnosisofdiabetes.(LevelofEvidence:B)AReportoftheAmericanCollegeofCardiologyACCF/AHAGuidelineforAssessmentofCardiovascularRiskinAsymptomaticAdults無癥狀人群心血管病風(fēng)險的評估第13頁MicroalbuminuriaCLASSIIaInasymptomaticadultswithhypertensionordiabetes,urinalysistodetectmicroalbuminuriaisreasonableforcardiovascularriskas-sessment.(LevelofEvidence:B)CLASSIIbInasymptomaticadultsatintermediateriskwithouthypertensionordiabetes,urinalysistodetectmicroalbuminuriamightbereasonableforcardiovascularriskassessment.(LevelofEvidence:B無癥狀人群心血管病風(fēng)險的評估第14頁Lp-PLA2CLASSIIbLipoprotein-associatedphospholipaseA2(Lp-PLA2)mightbereasonableforcardiovascularriskassessmentinintermediate-riskasymptomaticadults.(LevelofEvidence:B)無癥狀人群心血管病風(fēng)險的評估第15頁ECGCLASSIIaArestingelectrocardiogram(ECG)isreasonableforcardiovascularriskassessmentinasymptomaticadultswithhypertensionordia-betes.(LevelofEvidence:C)CLASSIIbArestingECGmaybeconsideredforcardiovascularriskassessmentinasymptomaticadultswithouthypertensionordiabetes(LevelofEvidence:C)無癥狀人群心血管病風(fēng)險的評估第16頁RestingEchocardiography

TransthoracicEchocardiographyCLASSIIbEchocardiographytodetectLVHmaybeconsideredforcardiovascularriskassessmentinasymptomaticadultswithhypertension(LevelofEvidence:B)CLASSIII:EchocardiographyisnotrecommendedforcardiovascularriskassessmentofCHDinasymptomaticadultswithouthypertension.(LevelofEvidence:C)無癥狀人群心血管病風(fēng)險的評估第17頁CarotidIntima-MediaThicknessonUltrasoundCLASSIIaMeasurementofcarotidarteryIMTisreasonableforcardiovascularriskassessmentinasymptomaticadultsatintermediateriskPublishedrecommendationsonrequiredequipment,technicalapproach,andoperatortrainingandexperienceforperformanceofthetestmustbecarefullyfollowedtoachievehigh-qualityresults.(LevelofEvidence:B)無癥狀人群心血管病風(fēng)險的評估第18頁CarotidIntima-MediaThicknessonUltrasound無癥狀人群心血管病風(fēng)險的評估第19頁PulseWaveVelocityandOtherArterial

Abnormalities:MeasuresofArterialStiffnessCLASSIII:Measuresofarterialstiffnessoutsideofresearchsettingsarenotrecommendedforcardiovascularriskassessmentinasymptomaticadults.(LevelofEvidence:C)無癥狀人群心血管病風(fēng)險的評估第20頁RecommendationforMeasurementof

Ankle-BrachialIndexCLASSIIaMeasurementofABIisreasonableforcardiovascularriskassessmentinasymptomaticadultsatintermediaterisk.(LevelofEvidence:B)無癥狀人群心血管病風(fēng)險的評估第21頁

RecommendationforExercise

ElectrocardiographyCLASSIIbAnexerciseECGmaybeconsideredforcardiovascularriskassessmentinintermediate-riskasymptomaticadults(includingsedentaryadultsconsideringstartingavigorousexerciseprogram),particularlywhenattentionispaidtonon-ECGmarkerssuchasexercisecapacity.(LevelofEvidence:B)無癥狀人群心血管病風(fēng)險的評估第22頁DukeTreadmillScore(DTS)

Theanginaindexhadavalueof0ifnoanginaoccurredduringexercise,1ifnon–test-limitinganginaoccurred,and2iftest-limitinganginaoccurred.Ascoreof5orgreaterwasconsideredlowrisk;between5and-10,intermediaterisk;andlessthan-10,highrisk.無癥狀人群心血管病風(fēng)險的評估第23頁ELECTROCARDIOGRAPHICSTRESSTESTING

FORSILENTMYOCARDIALISCHEMIA

ECGstresstestinghasanapproximate50%sensitivityand80%specificity.ThepositivepredictivevaluefordetectingCADusingcoronaryangiographyasthegoldstandardrangesbetween60%and94%andwashigherinmenthanwomen.Recommendationsforexercisestresstestingforriskassessmentdonotappeartobedifferentinpatientswithdiabetesandpatientswithoutdiabetes.無癥狀人群心血管病風(fēng)險的評估第24頁RecommendationforStressEchocardiographyCLASSIII:NOBENEFITStressechocardiographyisnotindicatedforcardiovascularriskassessmentinlow-orintermediate-riskasymptomaticadults.(ExerciseorpharmacologicstressechocardiographyisprimarilyusedforitsroleinadvancedcardiacevaluationofsymptomssuspecteofrepresentingCHDand/orestimationofprognosisinpatientswithknowncoronaryarterydiseaseortheassessmentofpatientswithknownorsuspectedvalvularheartdisease.)(LevelofEvidence:C)無癥狀人群心血管病風(fēng)險的評估第25頁MyocardialPerfusionImagingCLASSIIbStressMPImaybeconsideredforadvancedcardiovascularriskassessmentinasymptomaticadultswithdiabetesorasymptomaticadultswithastrongfamilyhistoryofCHDorwhenpreviousriskassessmenttestingsuggestshighriskofCHD,suchasaCACscoreof400orgreater.(LevelofEvidence:C)無癥狀人群心血管病風(fēng)險的評估第26頁ComputedTomographyforCoronaryCalciumCLASSIIaMeasurementofCACisreasonableforcardiovascularriskassess-mentinasymptomaticadultsatintermediaterisk(10%to20%10-yearrisk).(LevelofEvidence:B)CLASSIIbMeasurementofCACmaybereasonableforcardiovascularriskAssessmentinpersonsatlowtointermediaterisk(6%to10%10-yearrisk).(LevelofEvidence:B)CLASSIII:NOBENEFITPersonsatlowrisk(6%10-yearrisk)shouldnotundergoCACmeasurementforcardiovascularriskassessment.(LevelofEvidence:B)無癥狀人群心血管病風(fēng)險的評估第27頁CoronaryComputedTomographyAngiographyCLASSIII:NOBENEFITCoronarycomputedtomographyangiographyisnotrecommendedforcardiovascularriskassessmentinasymptomaticadults.(LevelofEvidence:C)無癥狀人群心血管病風(fēng)險的評估第28頁

MagneticResonanceImagingofPlaqueCLASSIII:MRIfordetectionofvascularplaqueisnotrecommendedforcardiovascularriskassessmentinasymptomaticadults.(LevelofEvidence:C)無癥狀人群心血管病風(fēng)險的評估第29頁缺血性心血管疾病(ICVD)10年發(fā)病危險度評定表(男)無癥狀人群心血管病風(fēng)險的評估第30頁缺血性心血管疾病(ICVD)10年發(fā)病危險度評定表(女)無癥狀人群心血管病風(fēng)險的評估第31頁強調(diào)重視心血管疾病危險評定40歲以上個體應(yīng)最少每5年進(jìn)行一次危險評定有2個以上危險原因個體，應(yīng)每年進(jìn)行一次危險評定。對絕對風(fēng)險低個體推薦使用“心血管疾病相對危險評定量表”無癥狀人群心血管病風(fēng)險的評估第32頁一級預(yù)防改進(jìn)生活方式降壓調(diào)脂抗栓治療降糖有效心血管事件一級預(yù)防辦法無癥狀人群心血管病風(fēng)險的評估第33頁規(guī)律運動改進(jìn)生活方式合理膳