Cardiovascular risk and cardiometabolic risk: an epidemiological evaluation
Cardiovascular risk and cardiometabolic risk: an epidemiological evaluation
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DOI：
10.1714/669.7808
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发表时间：
2008-04-01
影响因子：
0.5
通讯作者：
Pirelli, Salvatore
中科院分区：
文献类型：
--
作者：
Vanuzzo, Diego;Pilotto, Lorenza;Pirelli, Salvatore
在文献综述的基础上，本文讨论了全球心血管风险和心血管代谢风险的概念，指出了它们之间的联系，也指出了它们尚未解决的问题，并讨论了它们在临床实践中的实用性。全球心血管风险是指在一定时期内患冠状动脉事件或中风的概率，从这个意义上说，这是绝对风险，通常以10年的百分比报告。通常使用风险函数，从健康人群的基线纵向研究中得出。他们考虑了一些与人口分析事件密切相关的因素：其中有一些代谢因素（总胆固醇、高密度脂蛋白胆固醇、空腹血糖），一些生物因素（血压）和一些生活方式因素（吸烟），除了年龄和性别等不可改变的因素外，所有这些因素都是可以改变的。所选择的因素在多变量分析中必须是独立的，测量简单和标准化，并有助于显著增加风险函数的预测性。为了保证可靠性，这些风险函数必须来自稍后将对其进行管理的同一人群。因此，在纵向研究部分，意大利Progetto CUORE从80年代中期到90年代的纵向可比研究中建立了一个风险因素数据库，并对参与者的心血管死亡率和发病率进行了随访，以估计意大利男性和女性的全球心血管风险（首次冠状动脉或脑血管事件）。目前已经产生了两种工具，风险图表和评分软件（见www.cuore.iss.it）。肥胖症和糖尿病的持续流行，以及糖尿病与高血压和血脂异常等经典风险因素相关的事实，促使美国糖尿病协会和美国心脏协会发起了一项“行动呼吁”，以预防心血管疾病和糖尿病。在本文中，心脏代谢危险因素被认为是“与糖尿病和心血管疾病密切相关的：空腹/餐后高血糖、超重/肥胖、收缩压和舒张压升高、血脂异常”。心脏代谢风险因素之间的关联早已为人所知，其大部分病因都归因于胰岛素抵抗。此外，这些“代谢”异常可以聚集在许多个体身上，这一事实产生了“代谢综合征”一词，这一概念被许多组织所接受，但受到其他作者的质疑。从流行病学的角度来看，代谢综合征似乎适度地增加了患心血管疾病的风险，而在非糖尿病个体中，它更有效地预测了糖尿病。许多研究比较了经典的心血管评估工具（Framingham风险评分、score图表、Progetto CUORE评分）和代谢综合征在心血管疾病预测中的表现。通常，在高风险人群中，代谢综合征的存在并不会降低患心血管疾病的风险，而在低风险人群中，代谢综合征的存在却会显著增加患心血管疾病的几率。许多研究表明，积极的生活方式干预可以显著降低2型糖尿病的进展率。还有一些药物用于糖尿病预防，通常是在糖耐量受损的人群中进行的。联合使用口服糖尿病药物（阿卡波糖、二甲双胍、氟明、格列吡嗪、苯双胍）的效果不如生活方式干预，不同药物的效果不同；抗肥胖药物奥利司他对生活方式干预也有类似的结果。在意大利，心血管疾病和糖尿病预防的适当方法可能是首先使用Progetto CUORE的图表或评分软件评估全球心血管风险，因为高风险受试者（>= 20%）必须独立于代谢综合征的存在进行积极治疗；作为第二步，可能会寻找代谢综合征，因为它会增加风险；最后，对非糖尿病性高血糖患者应给予一定的注意。
On the basis of a critical literature review, this article deals with the concepts of global cardiovascular risk and cardiometabolic risk, pointing out their links but also their unresolved issues and discussing their usefulness in clinical practice.The global cardiovascular risk is the probability of suffering from a coronary event or stroke in a given period of time and in this sense it is an absolute risk, generally reported as percentage at 10 years. Usually risk functions are used, derived from longitudinal studies of healthy people at baseline. They consider some factors that are coherently linked with events in population analyses: among these there are some metabolic factors (total cholesterol, HDL cholesterol, fasting blood glucose), some biological factors (blood pressure) and some lifestyle factors (tobacco smoking), all modifiable beyond those non-modifiable like age and gender. The chosen factors must be independent at multivariate analysis, simple and standardized to measure, and contribute to significantly increase the risk-function predictivity. To be reliable, these risk functions must be derived from the same population where they will be later administered. For this reason the Italian Progetto CUORE, in the longitudinal study section, built a database of risk factors from longitudinal comparable studies started between the mid '80s and '90s and followed up the participants for cardiovascular mortality and morbidity to estimate the Italian global cardiovascular risk (first coronary or cerebrovascular event) for men and women. Two tools have been produced, the risk charts and a score software (see www.cuore.iss.it).The ongoing epidemics of obesity and diabetes and the fact that diabetes is associated with classical risk factors like hypertension and dyslipidemia induced the American Diabetes Association and the American Heart Association to launch a "call to action" to prevent both cardiovascular disease and diabetes. In this paper, as cardiometabolic risk factors were considered those "closely related to diabetes and cardiovascular disease: fasting/postprandial hyperglycemia, overweight/obesity, elevated systolic and diastolic blood pressure, and dyslipidemia". The association among the cardiometabolic risk factors has been known for a long time, and much of their etiology has been ascribed to insulin resistance. Also, the fact that these "metabolic" abnormalities can cluster in many individuals gave rise to the term "metabolic syndrome", a construct embraced by many organizations but questioned by other authors. From an epidemiological point of view the metabolic syndrome seems to increase modestly the cardiovascular risk, whereas in non-diabetic individuals it predicts diabetes much more efficiently.Many studies have compared the performance of the classical cardiovascular evaluation tools (the Framingham risk score, the SCORE charts, the Progetto CUORE score) and metabolic syndrome in cardiovascular disease prediction. Usually in people at high risk the presence of the metabolic syndrome does not improve the risk, whereas in people at lower risk its presence increases significantly the chances of cardiovascular disease. Many studies have shown that positive lifestyle interventions markedly reduce the rate of progression of type 2 diabetes. Also some drugs were tested for diabetes prevention, usually in people with impaired glucose tolerance. Oral diabetes drugs considered together (acarbose, metformin, flumamine, glipizide, phenformin) were less effective than lifestyle interventions, with different results among the drugs; the antiobesity drug orlistat gave similar results to lifestyle interventions.In Italy an appropriate approach to cardiovascular disease and diabetes prevention may be that of first evaluating the global cardiovascular risk using the charts or the score software of the Progetto CUORE, because high-risk subjects (>= 20%) must be treated aggressively independently of the presence of the metabolic syndrome; as a second step the metabolic syndrome may be sought, because it increases the risk; finally some attention should be paid to non-diabetic hyperglycemic individuals.