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Frequency of lipid abnormalities in male CHD patients

100. 87. 80. 64. 62. 60. Occurrence of abnormalities (%). 33. 40. 20. 0. Elevated total-C. Elevated LDL-C. Elevated triglycerides. Low HDL-C. Rubins HB et al. Am J Cardiol 1995;75:1196-1201. Frequency of lipid abnormalities in male CHD patients.

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Frequency of lipid abnormalities in male CHD patients

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  1. 100 87 80 64 62 60 Occurrence of abnormalities (%) 33 40 20 0 Elevatedtotal-C ElevatedLDL-C Elevatedtriglycerides LowHDL-C Rubins HB et al. Am J Cardiol 1995;75:1196-1201 Frequency of lipid abnormalities in male CHD patients

  2. Comparative efficacy in raising low HDL-C 45 40 35 30 25 HDL-C (mg/dL) Simva 20 vs Feno 200M Type IIb Steinmetz1 Prava 20/40 vs Feno 200M Ducobu2 Atorva 10 vs Feno 300S Heinonen3 Baseline Statin Fenofibrate 1Steinmetz, J Cardiovasc Pharmacol 1996;27:563–70 2Ducobu, Drugs 1997;54:615–333Heinonen, Abstract 66th Congress of the European Atherosclerosis Society, Florence 1996

  3. Fibrates: Regulation of lipoprotein metabolism by PPARa Fibrates PPAR PPAR PPARa RXR RXR A-I PPRE PPRE LPL PPAR PPAR RXR RXR A-II C-III PPRE PPRE HDL particles TG rich particles • Staels B et al. Circulation 1998;98:2088–93.

  4. PPARa activators induce cholesterol efflux from human macrophages Apo A-I Activated PPARa PPARa activator ABCA-1 geneexpression Relative decrease in cellular cholesterol after Apo A-I efflux 0 Cholesterolefflux 1 Human macrophages were cholesterol loaded with AcLDL in the presence of PPARa activator and incubated for 24 hours with apo A-I 2 Intracellularcholesterol 3 TC CE FC 4

  5. VA-HIT Study: Diabète type 2 & traitement par fibrate (1) • Bloomfield Rubins H et al. • Arch Intern Med 2002; 162: 2597-2604

  6. Facteurs de risque cardio-vasculaire • Sexe • Antécédents familiaux • Antécédents personnels • Lipides et lipoprotéines • Hypertension artérielle • Diabète • Insuffisance rénale chronique • Inflammations chroniques • Tabagisme • Mauvaises habitudes alimentaires • Sédentarité et activité physique insuffisante

  7. Nutrition et Pathologies Cardio-vasculaires Lipides plasmatiquesPression artérielleTendance aux thrombosesRésistance à insulineOxydationHomocystéineInflammationFonction endothélialeIrritabilité ventriculaire NUTRITION MCV

  8. Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-Reactive Protein 46 sujets adultes, sains mais hyperlipidémie 25 H; 21 F; 59  1 ans; BMI 27.6  0.5 Intervention : distribution aléatoire A : apports pauvres en graisses sat & riches en céréales ent. B : mêmes apports + Lovastatin 20 mg C : apports riches en phytostérols (1.0 g / 1000 kcal) protéines de soja (21.4 g / 1000 kcal) fibres visqueuses (9.8 g / 1000 kcal) amandes (14 g / 1000 kcal) D.J.A. Jenkins et al, JAMA, 2003

  9. Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-Reactive Protein D.J.A. Jenkins et al, JAMA, 2003

  10. Adherence to a Mediterranean diet and survival in a Greek population Etude prospective sur 22.043 adultes (20-86 ans) Evaluation des apports alimentaires Classification selon un «score  méditerranéen» Suivi sur 44 mois :  Adhésion au régime méditerranéen associée à  mortalité par maladies cardio-vasculaires et cancer Trichopoulou A et al, N Engl J Med, 2003

  11. Trichopoulou A et al, N Engl J Med, 2003

  12. Mediterranean Diet, Traditional Risk Factors, and the Rate of Cardiovascular Complications After Myocardial InfarctionFinal Report of the Lyon Diet Heart Study, de Lorgeril et al, 1999 Survie sans complication Survie sans I.M. non mortel

  13. All participants: Step 1 Prudent Diet National Cholesterol Education Program + Regular physical activity + Fruits: 250-300g per day + Vegetables: 125-150g + Nuts: 25-50g walnuts/almonds + 400-500g/day of whole grains: legumes, rice, maize, wheat + 3-4 servings mustard / soy bean oil Intervention A 499 Control Group B 501 ALL: 1-week Food Records, Wt, BP & Metabolic Profiles Follow up: weekly, monthly, 3-monthly to 2 years End Points: 1 Myocardial Infarction - fatal /nonfatal 2 Sudden Cardiac Death, 3 Composite total of cardiac events The Indo-Mediterranean diet heart study, R. Singh et al, Lancet, 2002

  14. Change in Risk factors during study:Both groups improved significantly, but more so in Gp A, p<0.001 for all parameters The Indo-Mediterranean diet heart study, R. Singh et al, Lancet, 2002

  15. Numbers & rate ratios for cardiac endpoints, adjusted for age, gender, BMI, cholesterol and BP Group A B Rate Group A B Rate 499 501 Ratios 499 501 Ratios Non Fatal MI 21 43 0.47 [0.28 - 0.79] Non Fatal MI 21 43 0.47 [0.28 - 0.79] Fatal MI 12 17 0.67 [0.31 - 1.42] Fatal MI 12 17 0.67 [0.31 - 1.42] Sudden cardiac 6 16 0.33 [0.13 - 0.86] Sudden cardiac 6 16 0.33 [0.13 - 0.86] death death Total Cardiac Total Cardiac Endpoints 39 76 0.48 [0.33 - 0.71] Endpoints 39 76 0.48 [0.33 - 0.71] The Indo-Mediterranean diet heart study, R. Singh et al, Lancet, 2002

  16. Conclusions • The Indo Mediterranean diet is a safe and economical means for improving the health of poorer populations • The whole grains, fruits, vegetables and oils used in this study were traditional fare, grown by farmers at the present market cost of about1 US$ per day Lancet 2002 The Indo-Mediterranean diet heart study, R. Singh et al, Lancet, 2002

  17. 11,323 patients randomized 2835 given omega-3 PUFAs 2830 given vitamin E 2830 given omega-3 PUFAs & vitamin E 2828 controls 4 lost to follow-up 687 discontinued vitamin E 11 received omega-3 PUFAs 4 lost to follow-up 848 discontinued omega-3 PUFAs 808 discontinued vitamin E 2 lost to follow-up 15 received omega-3 PUFAs 2 received vitamin E 3 lost to follow-up 768 discontinued omega-3 PUFAs 2835 analysed for outcomes 2828 analysed for outcomes 2830 analysed for outcomes 2830 analysed for outcomes GISSI-Prevenzione Trial: Design GISSI-Prevenzione Investigators. Lancet 1999;354:447-455; Marchioli R et al. Eur Heart J Suppl 2001;3(Suppl D):D85-D97.

  18. GISSI-Prevenzione Trial:Secondary Endpoint Results Control Omega-3 Risk P-value PUFAs reduction All-cause mortality 10.6% 8.4% 21% 0.0064 CV death 7.2% 5.1% 30% <0.001 Cardiac death 6.1% 4.0% 35% <0.001 Coronary death 5.2% 3.6% 32% <0.01 Sudden death 3.3% 1.8% 44% 0.0006 Non-fatal CV events 4.9% 4.9% 2% n.s. Marchioli R et al. Eur Heart J Suppl 2001;3(Suppl D):D85-D97; Marchioli R et al. Circulation 2002;105:1897-1903.

  19. 1.00 0.99 Omega-3 PUFAs 0.98 Probability 0.59 (95% CI 0.36-0.97) P = 0.037 0.97 Control 0.96 0.95 120 150 360 210 270 330 0 30 180 90 240 300 60 Days GISSI-Prevenzione Trial: Early Effect of Omega-3 PUFAs on All-Cause Mortality Calculated adjusting for treatment interaction and major confounding variables Marchioli R et al. Circulation 2002;105:1897-1903.

  20. Modifications des recommandations • Réduire apports en graisses saturées (animales) • Remplacement par graisses mono-insaturées (olive, …) • Inclusion et augmentation des acides gras oméga-3 • Réduction des sucres simples • Remplacement par sucres lents (féculents, pâtes, pain entier, …) • Retour aux céréales entières (fibres) notion de mauvaises & bonnes graisses mauvais et bons sucres

  21. Modes de nutrition protecteurs • Régime(s) méditerranéen(s) • Adaptation possible à goûts/cultures différents •  graisses saturées  sucres simples •  légumes et/ou fruits (y compris fruits secs) • Apports caloriques raisonnables • Apports protéiques raisonnables • Vin en quantité modérée (sauf si contre-indications) font partie d’un mode de vie (« lifestyle »)

  22. Nutrition et Maladies c.v. : les messages • Lésions d’athéroslérose souvent réversibles • Réduction du risque par mode de vie (-50% à –80%) • Suppléments alimentaires : NON, sauf si indications: stérols végétaux acides gras oméga-3 acide folique (sélénium)

  23. Modifications du mode de vie • Arrêt cigarette • Alimentation « santé » sélection aliments / nutriments plaisants & sains •  activité physique (régulière) •  risque cardio-vasculaire ( - 80%) • Effet additif à celui des médicaments ( lipides, tension artérielle)

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