Mieli skaitytojai,

Mieli skaitytojai,

 

Žaneta Petrulionienėvėl noriu su jumis pasidalyti ką tik gautomis žiniomis. Europos aterosklerozės draugija (angl. European Atherosclerosis Society – EAS) 86-ajame kongrese, įvykusiame Lisabonoje šių metų gegužės mėnesį, kaip ir kasmet įvykdė savo pažadą ir paskelbė svarbiausias aterosklerozės ir kardiovaskulinių ligų naujienas. Tarp daugybės svarbių temų buvo išskirtos kelios prioritetinės: kardiovaskulinės sveikatos užtikrinimas XXI amžiuje; aterosklerozinės plokštelės supratimo, nustatymo bei gydymo pokyčiai; lipoproteino (a) renesansas. Be to, buvo aptartas naujausias Europos aterosklerozės draugijos Specialistų grupės Susitarimo dokumentas apie nepageidaujamus gydymo statinais reiškinius. Šis dokumentas atskyrė įrodymais pagrįstus duomenis nuo nepagrįstų įžvalgų.

 

Europos aterosklerozės draugijos Susitarimo dokumentas dėl nepageidaujamų statinų reiškinių

 

Profesoriaus M. Johno Chapmano (INSERM and the University of Pierre and Marie Curie, Paris, France) pristatytas naujausias Europos aterosklerozės draugijos Specialistų susitarimo dokumentas dėl statinų nepageidaujamų reiškinių sulaukė didelio susidomėjimo. Šio dokumento tikslas buvo objektyviai įvertinti nepageidaujamus statinų reiškinius, labiausiai atkreipiant dėmesį į gliukozės homeostazę, kognityvinę, inkstų ir kepenų funkciją, taip pat hemoraginio insulto riziką bei kataraktą, atsižvelgiant į pacientų nuomonę ir jų įtarimus apie statinų nepageidaujamus reiškinius.

Dokumente išsakyta specialistų nuomonė, kad statinų kardiovaskulinė nauda gerokai viršija bet kokio nepageidaujamo reiškinio riziką. Pripažinta, kad gydymas statinais yra susijęs su nedidele naujai diagnozuoto cukrinio diabeto rizika, maždaug vienas naujas atvejis 1 tūkst. pacientų per metus, rizika didesnė turintiems metabolinio sindromo požymių. Tačiau šie duomenys turi būti patikrinti ir palyginti su naujo cukrinio diabeto atvejų dažniu asmenims, nevartojusiems statinų. Nenustatyta jokio neigiamo poveikio kognityvinei ar inkstų funkcijai; kliniškai reikšmingas poveikis kepenims buvo labai retas. Tyrime SPARCL (angl. Stroke Prevention by Aggressive Reduction in Cholesterol Levels) pastebėtas nežymus hemoraginio insulto rizikos padidėjimas pacientams po seniau persirgto insulto nebuvo patvirtintas po išsamios visos prieinamos literatūros apžvalgos. Taip pat nerasta įrodymų, kad gydymas statinais galėtų būti siejamas su katarakta.

 

Kardiovaskulinė sveikata iš populiacijos perspektyvos

 

Seniai pripažinta, kad aterosklerozė yra lėtinė uždegiminė liga. Ji vystosi dešimtmečiais, o jos kulminacijoje įvyksta klinikinės komplikacijos, tokios kaip miokardo infarktas. Garsus profesorius Valentinas Fusteris (Mount Sinai Heart, New York, USA) kongreso atidarymo plenarinėje sesijoje išsakė įdomią mintį: Iki šiol prevencinės strategijos buvo fokusuojamos į kardiovaskulinių rizikos veiksnių valdymą, siekiant sustabdyti arba sulėtinti aterosklerozės progresavimą iki klinikinių apraiškų. Nauja taktika siūlo dėmesį atkreipti į kardiovaskulinės sveikatos užtikrinimą, idealiu atveju pradėti kiek galima jaunesnio amžiaus pacientams, o tai neabejotinai duotų daug daugiau naudos tiek individualiai kiekvienam, tiek ir visai visuomenei.

Šis požiūrio pasikeitimas yra svarbus dėl kelių priežasčių.

Pirma, prevencines priemones taikyti net mažos rizikos vidutinio amžiaus asmenims yra neabejotinai per vėlu. Pavyzdžiui, tyrimas PESA (angl. Progression of Early Subclinical Atherosclerosis), kuriame dalyvavo apie 4 tūkst. vidutinio amžiaus asmenų, parodė, kad pusė jų jau sirgo subklinikine aterosklerozine liga, nepaisant tradicinių kardiovaskulinių rizikos veiksnių nebuvimo. Be to, jaunų suomių tyrimas (angl. Young Finns Study) parodė, kad kardiovaskulinių rizikos veiksnių poveikis paauglystėje predisponavo kraujagyslių pokyčius ir aterosklerozės išsivystymą suaugus, taip pat turėjo įtaką kardiovaskulinei sveikatai ir kognityvinei funkcijai vėlesniu laikotarpiu.

Antra, sveikatos apsaugos sistemų ištekliai, skiriami sergančiųjų kardiovaskulinėmis ligomis priežiūrai, yra riboti ir senkantys. Kaip pabrėžė profesorius Salimas Yusufas (Population Health Research Institute, Hamilton, Canada), padėtis kelia susirūpinimą mažų ir vidutinių pajamų šalyse, kuriose išlaidos net generinėms prevencinėms priemonėms, tokioms kaip aspirinas, statinai ir kraujospūdį mažinantys vaistai, sudaro didesnę dalį šeimos pajamų. Duomenys, pateikti studijoje PURE (angl. Prospective Urban Rural Epidemiology), parodė, kad apie 40 proc. asmenų, gyvenančių mažų ar vidutinių pajamų šalyse, nepajėgūs nusipirkti nė vieno iš keturių vaistų (aspirino, beta adrenoblokatoriaus, angiotenzino receptorių blokatoriaus ar statino), kurie yra rekomenduojami kardiovaskulinių ligų prevencijai. Tai akivaizdus įrodymas, kad rizikos veiksnių valdymas tokiuose regionuose yra būtinas. Pavyzdžiui, Azijoje tik 10 proc. asmenų pasiekiama patenkinama hipertenzijos kontrolė.

Trečia, tampa akivaizdu, kad kardiovaskulinės rizikos vertinimą būtina praplėsti už tradicinių rizikos veiksnių ribų. Mus supanti aplinka ne tik daro didelę netiesioginę įtaką gyvensenos rizikos veiksniams, pavyzdžiui, metimui rūkyti, fizinio aktyvumo padidinimui, mitybai, bet turi ir tiesioginį poveikį. Pavyzdžiui, tyrimas PURE parodė ryšį tarp ore esančių kietųjų dalelių (kurių vidutinis aerodinaminis diametras <2,5 µm) kiekio padidėjimo ir kardiovaskulinių įvykių. Nors tai riziką padidina tik vidutiniškai, tačiau ekspozicijos padidėjimas (5 proc. per 10 mg/m3) paveikia labai didelį skaičių žmonių, todėl veikia populiacijos sveikatą. Dar daugiau, yra duomenų apie etninius oro taršos poveikio skirtumus.

Atėjo laikas atkreipti dėmesį į gerokai daugiau rizikos determinančių nei klasikiniai rizikos veiksniai, tokie kaip lipidai. Iš tiesų kongreso jungtinėje sesijoje kartu su Europos kardiologų draugija (angl. European Society of Cardiology – ESC) profesorius Diederickas Grobbeeʼas (University Medical Center Utrecht, Netherlands) pasiūlė naują terminą – exposome, apimantį įvairių poveikių ir jų kontekstų visumą. Iš esmės tai apima natūralios ir socialinės aplinkos veiksnius, taip pat kultūrinės, ekonominės veiklos veiksnius, socialinius tinklus, kurie gali daryti poveikį kardiovaskulinei sveikatai. Išmaniosios technologijos siūlo inovatyvius metodus (omics) ir naują požiūrį į kardiovaskulinę sveikatą.

Taigi populiacijos kardiovaskulinių ligų prevencijos principas, sveikatos propagavimas kuo anksčiau, kartu taikant prevencines strategijas didelės rizikos asmenims, yra neabejotinas kelias pirmyn, vedantis globalios kardiovaskulinių ligų naštos sumažinimo link.

 

Naujos įžvalgos apie aterosklerotinę plokštelę

 

Kongrese ekspertai diskutavo, ką reiškia ženkli aterosklerozė vaizdinimo tyrimuose. Europos kardiologų draugijos prezidentas Jeroenas J. Baxas dėmesį atkreipė į didelės rizikos žymenų panaudojimą ir pabrėžė, kad nors kai kurie jų pasižymi dideliu diagnostiniu tikslumu, vis dėlto teigiamas testas nėra geriausias pasirinkimas pacientų priežiūrai, ypač tų, kurių rizika yra tarpinė. Tuo tarpu anatominio ir funkcinio vaizdinimo integravimas turi pranašumų nustatant ženklią aterosklerozę. Reikalingos tolesnės inovacijos, ypač nekalcifikuotiems didelės rizikos pažeidimams diferencijuoti. Profesorius Gerardas Pasterkampas (University Medical Center Utrecht, Netherlands) papildė, kad, nepaisant progreso vaizdinimo technikos srityje, aterosklerotinių plokštelių charakterisktikai įvertinti kraujagyslių vaizdinimo metodai nėra rutiniškai naudojami. Be to, pagerėjusi terapinė priežiūra pakeičia plokštelių morfologiją.

Europos aterosklerozės draugijos prezidentės Lale Tokgozoglu nuomone, daugiarūšis multimodalus vaizdinimas galėtų padėti išspręsti šį neaiškumą, tačiau kiekvienam pacientui reikėtų parinkti optimalų vaizdinimo metodų derinį ir iki minimumo sumažinti apšvitos riziką. Iš kitos pusės, tiksliai atrinktos ir pritaikytos prevencinės strategijos, paremtos genetika, biožymenimis ir vaizdinimu, gal ir yra tas kelias, kuriuo turėtume eiti.

 

Lipoproteinas (a): nauji duomenys

 

Daugiau nei po 60 metų šiuo metu stebimas susidomėjimo lipoproteinu (a) atgimimas. Esminiu varikliu tapo Europos aterosklerozės draugijos Specialistų susitarimo dokumentas apie lipoproteiną (a), kuriame, įvertinus mechanistinius, observacinius ir genetinius įrodymus, daroma išvada, kad yra priežastinis ryšys tarp lipoproteino (a) ir kardiovaskulinių ligų. Vis dėlto trūko įrodymų iš intervencinių studijų. Europos aterosklerozės draugijos kongrese pristatytoje studijoje FOURIER (angl. Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk) pacientams MTL cholesterolį intensyviai sumažinus PCSK9 inhibitoriumi, kardiovaskulinių įvykių rizika liko didesnė tiems, kurių lipoproteino (a) kiekis buvo didžiausias, palyginti su tais, kurių jis buvo mažiausias.

 

Apie ką dar buvo kalbama karščiausių naujienų sesijoje?

 

Pirma, pristatytos klinikinio tyrimo ORION-1 naujienos. Naujas injekcinis vaistas inklisiranas, veikiantis genetiniu lygmeniu per RNR ir inhibuojantis intraląstelinę PCSK9 sintezę, ne tik sumažina MTL cholesterolį, bet ir kitus aterogeninius lipoproteinus, apolipoproteiną B, ne -DTL cholesterolį, lipoproteiną (a). Palaikomasis gydymas, kartojamas kas 6 mėnesius, turi privalumų, yra patogus pacientui ir labai pagerina paskyrimų laikymąsi.

Antra, paskelbtos pirmosios naujienos iš antrinės prevencijos tyrimo EUROASPIRE V, kuriame dalyvavo įvairių Europos valstybių pacientai, praėjus metams po hospitalizavimo dėl ūminio koronarinio sindromo ar revaskuliarizacijos. Tyrimas parodė, kad antrinės prevencijos srityje dar daug ką reikia nuveikti ir gerinti gairių pritaikymą praktikoje. Tyrimas apibendrino 8 261 antrinės prevencijos paciento duomenis (vidutinis amžius – 64 metai, 26 proc. moterų), kuriuos pateikė 131 centras iš 27 šalių. Nors dauguma pacientų (84 proc.) gavo lipidus mažinantį gydymą (vyravo statinai), tik vienas iš trijų (32 proc.) pasiekė MTL cholesterolio tikslą <1,8 mmol/l. Labiausiai tai galima paaiškinti faktu, kad mažiau nei pusė pacientų palaikomajam gydymui gavo didelio intensyvumo gydymą statinais po išrašymo iš ligoninės. Kongrese pristatant tyrimą EUROASPIRE V, Lietuva keletą kartą buvo paminėta kaip blogiausius dislipidemijų gydymo rezultatus turinti šalis.

 

Peržvelgiau tik mažą dalį Europos aterosklerozės draugijos kongrese Lisabonoje pateiktos informacijos. Buvo labai daug ir kitų įdomių naujienų. Birželio pradžioje vyks dar didesnis renginys – Tarptautinės aterosklerozės draugijos (angl. International Society of Atherosclerosis – ISA) XVIII pasaulinis Aterosklerozės simpoziumas. Ten bus dar įdomesnių dalykų. Apie tai – kitą kartą.

 

Linkėjimai visiems ir kiekvienam asmeniškai

 

Prof. Žaneta Petrulionienė

 


169 mintys apie “Mieli skaitytojai,

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