Angiologia

#30 Best Foods That Help Unclog Your Arteries

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According to the World Health Organization, around 26% of deaths in 2015 were due to heart disease, also known as coronary artery disease. If you’re safe from poverty-related diseases, then your chances of suffering from heart issues will be even higher than this. Around 1 in 3 deaths in the United States are heart-related, claiming more lives than all forms of cancer combined.

The most common cause of heart problems is the build-up of plaque on the inner walls of arteries that go to the heart. Arteries are large blood vessels that connect the heart to the rest of the body and carry oxygen and nutrients to/from the heart and the rest of the body. They should be flexible and elastic to efficiently deliver blood, but age and plaque build-up can make them less elastic and harder.

Plaque is made up of an accretion of blood, cholesterol fats and other substances that clog or even block the arteries to the point where less blood can flow through the heart and a heart attack ensues. Where the heart cannot deliver enough blood to the brain, a stroke can result in damaging parts of the brain. A weak heart can cause or make worse any number of other symptoms which can be directly or indirectly life-threatening.

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The clogging up of the arteries is, in part, due to a bad diet and poor lifestyle choices. It is said that only one percent of people eat what doctors recommend as a healthy diet, so it is likely that the rest of us can do better to clean up our act – and our arteries.  Fortunately, it is possible to prevent and even reverse the arterial damage by eating well and living a healthy lifestyle.

1. Garlic

Garlic is well-known for its many health-boosting characteristics.  It is rich in anti-oxidants, such as vitamins C and E, which remove free radicals.  When the cells absorb oxygen from the body, the chemical reaction releases by-products which can damage healthy cells. These are the free radicals which garlic helps remove.  It can reduce levels of bad LDL cholesterol, help to widen blood vessels, improve blood circulation and prevent hardening of the aorta.

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Regular intake of garlic will also help regulate your blood pressure and blood sugar levels.  It has been known for millennia as an effective means of cleaning the blood and is said to have a large number of health benefits, including helping to fight certain types of cancers, colds & flu, Alzheimer’s & dementia. It is also said to have antibacterial and anti-parasitic properties. All these other health benefits will take a little pressure off your heart as well.

Medical experts recommend you eat two full cloves of raw garlic every morning – on an empty stomach no less.  Unfortunately, the compounds which are most positive for cleaning the blood are the same ones which cause the infamous garlic smell – eating some parsley can help with this. You can also add garlic to most recipes, just remember that the health benefits of garlic are derived from fresh, raw, or lightly cooked garlic, only – so don’t overdo the cooking!

Aged garlic extract (AGE) can be taken as a supplement as well and is not quite so smelly or difficult to digest as raw garlic. Since garlic works as a blood thinner, make sure that you don’t have any health conditions that can be made worse by this, or that you are not already taking prescribed blood thinning medicine. As always, if in any doubt, consult your doctor before taking any supplements and boosting your garlic intake.

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2. Pomegranates

The deep red color of this fruit is a sign that it is packed with anti-oxidants, like berries.  Pomegranate seeds contain polyphenols (anti-oxidants) which have many health benefits and the seeds themselves are a valuable source of nutrients and fiber. A single pomegranate can supply 40% of your daily Vitamin C requirement alone. Just be careful if you are on blood pressure or cholesterol medications, as they may react badly to the fruit.

Initial studies point to pomegranates having blood thinning properties, as well as working against clogging or stiffening of the arteries.  The wide range of antioxidants also helps to clean the blood.  The fruit is also considered beneficial for lowering blood pressure, fighting prostate cancer, anti-inflammatory properties (it is particularly useful for the digestive system) among many other benefits.   Again, foods that help the heart provide a range of benefits for the whole body.

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As the fruit is only available seasonally, most likely much of your intake of pomegranates is going to be in juice form or as a supplement capsule.  Fortunately, the juice itself contain more anti-oxidants than most fruit juices. Remember that fruit juices have already lost their healthy fiber and may have lost much of their nutritional benefits if they have been processed or pasteurized.   What you thought was a healthy option may turn out to be little more than sugar-water (fructose).

Choose fresh fruit itself when you can or make sure you drink fresh fruit juice. Unfortunately, the cheaper brands may simply lack the health benefits you seek when you buy fruit juice. While it might look daunting, removing the “meat” from a pomegranate is easier than it might appear – rolling it before cutting it can help to loosen the seeds and submerging the cut fruit in water will help to soften the pith, allowing you to easily whack the seeds out.

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3. Asparagus

Asparagus is a low-calorie, high-fiber vegetable filled with nutrients which make it a natural addition to a healthy diet, especially if one is interested in losing weight.  However, it can improve the health of your heart as well. Homocysteine is an amino acid in the blood, usually derived from eating meat.  High levels of homocysteine are often indicative of heart disease and may cause damaged blood vessels, blood clotting in the veins, which can all damage the heart.

The B-vitamins in asparagus, especially folate, all help convert homocysteine into a safer molecule and thus reduce the damage caused to the heart. Asparagus also has a beneficial influence on the body’s production of glutathione, an antioxidant which helps combat inflammation and remove the free radicals which can lead to clogged or blocked arteries. Glutathione will also combat cancerous cells and promote strong bones.

Asparagus is a very good source of vitamin K which work to prevent hardening of the arteries and reduce calcium build-up in the arteries. Eat this tasty vegetable on a regular basis as much as possible. You can eat it as an appetizer or side dish and is a wonderful addition to a salad.  Apart from the damage that over-cooking will do to the health benefits of the vegetable, asparagus is a tender plant so treat it gently.

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It is best served lightly steamed or sautéed. A little olive oil, which has its own health benefits, goes very nicely together. Asparagus comes in three varietals, white, green or purple. While they are all great, the purple one has the edge in terms of nutrients.  Although not associated with how the vegetable tastes, some people pick up a strange smell in their urine after eating asparagus.  This does not indicate anything harmful at all.

4. Avocados

The recent rise in the popularity of Avocados has as much to do with their flavor and utility as with their health benefits.  Strangely enough, the avocado tree should have died out in its South American home centuries ago, along with the giant ground sloth which was the only dispersal agent left for its giant seed, but which became extinct 13,000 years ago. It is thanks to humans’ enjoyment of this fruit that we still have avos today.

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Containing 20 different nutrients, the fruit, sometimes called the alligator fruit, packs 2 grams of protein and 15 grams of healthy fats. Most of the carbohydrates are healthy fiber.  It has many anti-oxidant nutrients and is especially high in potassium, which helps reduce blood pressure.  Although bananas are well-known for their high potassium content, Avocados have twice the amount so are even better.

Avocados help the heart by reducing the “bad” cholesterol fats in the blood and increasing the “good” cholesterol, which helps clear arteries of blockages.  Their ability to be used as tasty substitutes for many unhealthy foods makes them especially attractive as health foods.  The healthy oils in Avocados will also help you better absorb nutrients in vegetables such as vitamins A, D, E and K which needs to be combined with fats to be absorbed by the body.

For a health food, Avocados are surprisingly tasty and can be included in your diet in so many ways.  While their softness makes them a favorite baby food, they can be crushed on toast for a healthy snack or used in salads either in slices or softened as a dressing to replace high-fat mayonnaise or other unhealthy salad dressings – guacamole has Avocados as their main ingredient after all.  You can find a use for Avocados at every meal of the day!

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5. Broccoli

While every child learns the nutritious benefits of green, leafy vegetables, they are rarely the most enjoyable item at the dinner table.  While other vegetables, such as spinach, are known for their health benefits, broccoli has the advantage in terms of taste and popularity. Fat-free and high in fiber, broccoli boasts a wide array of nutrients. it is high in fiber, very high in vitamin C and has potassium, B6, and vitamin A, as well as a large amount of protein for a vegetable.

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These nutrients are all anti-oxidants which remove unstable molecules from the body before they damage cells, and thus combat cancer and clogged arteries. Broccoli also enjoys high levels of phytochemicals which give plants their color, smell, and flavor, but which also benefit the immune system. The fiber can combine with bad cholesterol and remove it from the body, thus reducing harmful cholesterol levels in the blood.

In addition to reducing cholesterol, the sulforaphane in broccoli is an anti-inflammatory which can prevent or reverse damage to blood vessel linings caused by chronic blood sugar problems. And the vegetable’s B-complex vitamins can help regulate or reduce excessive homocysteine, which is associated with heart disease by converting it to a less harmful molecule.

Usually sautéed or steamed, I recommend you try a whole head of broccoli roasted in the oven with olive oil.  Boiled, (which often means over-boiled) broccoli is the least healthy way of preparing it because of most of the nutrients leach out into the water. It can be eaten raw, although it is often combined with a crudité dip which undoes all the healthy benefits of the vegetable itself. The young vegetables make an interesting addition to a salad.

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6. Oatmeal

While it has been known for many years that oatmeal can help reduce cholesterol, which can clog up arteries, new research has discovered additional benefits:  Some of the fiber in oats is called beta-glucan which reduces LDL cholesterol, non-HDC cholesterol, and apoB which carries cholesterol through the blood.  This means that oatmeal is particularly good at improving cholesterol measures because it improves three different factors.

Fibre is, of course, good for digestion as well and oats offer more soluble than other grains, which is an extra benefit. Beta-glucan, being a soluble fiber, actually slows down digestion in the intestines. This helps to keep blood-sugar levels more stable as the body doesn’t absorb sugar so quickly – which can also benefit diabetes sufferers. It also appears to help stimulate the immune system, though this has not been clinically proven as yet.

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There is a particularly powerful anti-oxidant found almost exclusively in oats, called avenanthramides. Avenanthramides are thought to lower blood pressure levels by increasing the production of nitric oxide in the blood. This gas molecule helps dilate blood vessels and leads to better blood flow.  In addition, oats contain a particularly powerful anti-oxidant called ferulic acid which is not only more powerful than vitamin E and C, but it enhances the abilities of the other-anti-oxidants.

Instant oats are less nutritious because they have been processed more. Rolled, crushed or steel-cut oat is preferred. Proper oatmeal is a gluten-free whole grain and a great source of important vitamins, minerals, fiber, and antioxidants.  Half a cup of oats will contain a balanced selection of nutrients as well as 51 grams of carbs, 13 grams of protein, 5 grams of fat and 8 grams of fiber, but only 300 calories. This means that oats are among the most nutrient-dense foods you can eat.

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7. Oily Fish

Oily fish refers to fish such as salmon, mackerel, tuna, herring, and sardines. Fish oil is full of omega-3 fatty acids which can help lower the risk of heart disease, improve mental ability, and protect against cancer, dementia, and arthritis.  Fish are probably the only food which can provide us with vitamin D. While lack of Vitamin D is usually associated with lack of exposure to sunlight, fear of skin cancer has begun to cause Vitamin D deficiency even in sunny countries.

Fish oils are also particularly good at lowering the level of a certain type of fat in the blood – triglycerides – an excess of which can collect in your arteries and clog them. Fish oils also help to lower blood pressure slightly, reduce blood clotting, lower heart and stroke risks and reduce irregular heartbeats. They also increase the levels of the “good” cholesterol, HDL.  Of course, they are also a good source of protein with low-fat content.

As attractive as fish seem to be in terms of healthy eating, it is possible (but unlikely) to eat so much fish that the levels of fish oils become dangerous.  In addition, fish high on the marine food chain, such as tuna, may contain high levels of poisonous heavy metals such as mercury.  Pregnant women should be careful about eating certain kinds of fish, though the Omega-3s in fish oil is essential for the baby’s early growth and development.

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The oil in oily fish is also useful for carrying certain nutrients which depend upon fat to be absorbed into the body, which makes fish particularly healthy. As is common with most foods that benefit the heart, eating fish regularly offers a variety of other health benefits many other areas of the body.  Try to eat fish at least twice a week, preferably with a meal that contains some fat which helps it to be absorbed. If you are allergic to fish, walnut oil is similar in nature

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8. Nuts

Nuts contain a lot of goodness in a small package. They are a good source of unsaturated fatty acids (the good fat) in the form of both monounsaturated fat and polyunsaturated fat (omega-6 and omega-3). They are easy to store, provide lots of fiber, protein, and nutrients and can easily be eaten on the go – this makes them an easy alternative to unhealthy snacks.  They might be one of the reasons why the Mediterranean diet is so healthy.

Just be careful not to eat too many because they are high in calories and many of us like the salted varieties – and salt is also better in small quantities.  And of course, some people are allergic to certain types.  The evidence on whether nuts are good for your heart is yet to be fully clarified.  However, there is evidence that specific nuts can have a beneficial effect on your heart, your blood sugar, and many other chronic diseases.

Almonds, for example, can lower your bad cholesterol level (LDL) while also working to help you reduce your weight, which is always a good thing.  They are high in protein and fiber and contain vitamin E, calcium, copper, and magnesium. Eating pistachios will help lower your blood pressure when you’re under stress, while also helping reduce your LDL level.  Walnuts are noted for their high levels of good fats, increasing HDL (good cholesterol) and lowering LDL.

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Peanuts, (which are actually a type of bean) are often considered to be less healthy than tree nuts, but actually, do offer many of the same benefits. Various studies have shown a good impact on heart problems and Type 2 diabetes. However, eating too many of them can hit your waistline worse than tree nuts might, and of course, most of our peanut snacks are salted, so be careful.  All other nuts have similar general health benefits, so don’t limit yourself to the ones listed above.

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9. Olive Oil

Olive oil is the pressed oil from olives – in its pure form, it is known as extra virgin olive oil. If it’s not extra virgin, it means it has been refined or diluted with cheaper oils and is therefore not as good for you. Extra virgin olive oil is high in antioxidants and contains vitamins E and K plus the good fatty acids. Olive oil has its own anti-inflammatory properties, which can also help keep your arteries strong and working well.

The beauty of olive oil is that it is so much tastier than most of its alternatives and can be added to your diet in so many ways.  It is also a great substitute for some of the worst offenders in our diet, such as polyunsaturated fats and butter. Did you know that in many Middle Eastern countries, olive oil is the go-to spread for bread and toast rather than butter? It is also so much easier to spread on a cold day and is great for dipping your bread into with a little bit of balsamic vinegar added.

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Even though it is a “good” fat, it is still a fat which should be eaten in moderation. While the benefits of olive oil in your diet is known from population studies, scientists in the laboratory still don’t fully understand why olive oil is good for your heart. However, there does seem to be signs that the combination of olive oil and green vegetables creates a molecule called “nitro fatty acid” which can relax blood vessels and reduce blood pressure.

The other benefit of olive oil is that it is so easy to combine with other foods which benefit the heart, such as asparagus, garlic or even broccoli.  If you’re like me, thinking about the Mediterranean diet takes you to Italy, which has enough wonderful recipes to keep you going for years.  Just remember that each and every country around the Med has its own wonderful tastes to discover, many of which include olive oil.

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10. Coffee

While in the past coffee has been generally considered bad for heart health, researchers have started looking beyond caffeine and found that coffee contains many other compounds which make it less bad for you than previously thought, and may even promote heart health.  While caffeine can exacerbate the symptoms of people who suffer from an irregular heartbeat, there doesn’t seem to be evidence that caffeine will actually cause arrhythmia.

The old belief that coffee can cause high blood pressure is also not true.  While it doesn’t cause high blood pressure, coffee can still worsen symptoms for people who suffer from it. In fact, population studies have shown that coffee drinkers enjoy a lower risk of heart-related problems than the general population.  However, notwithstanding these health benefits, too much coffee can be a problem.

As with all the foods listed here, coffee boasts a high concentration of polyphenols—the antioxidants which help offset inflammatory mediators in the blood and which help protect the whole body from a wide range of illnesses, not just heart disease. It seems that coffee supports the endothelial cells which line the arteries and thus allow better blood flow so that the heart has less strain and thus reduces the likelihood of heart issues.

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There is also broad evidence that coffee intake has other general health benefits and that it can help ward off Alzheimer’s and cancer.  Just remember that the sugar you add to your coffee is still bad for your health.  Experiment with different types of coffee and ways of brewing coffee to find one which you might enjoy without milk or sugar. With a little determination, you might find that you enjoy black coffee with no sugar.

11. Coconut oil

Coconut oil has enjoyed some highs and lows recently. First touted as the latest “super-food”, it was then found to increase bad (LDL) cholesterol in the blood – it has more saturated fat (the bad one) than butter. In fact, it consists of nearly 90% saturated fatty acids. It also boosts good (HDL) cholesterol production and has been shown to reduce weight and waistlines in people with heart issues (all helpful things in warding off heart disease).

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Recent research has shown that the saturated fat found in coconut oil is not the same as the “bad” saturated fat you find in butter or meat. The Medium Chain Triglycerides (MCTs) that make up coconut oil’s saturated fat are dealt with by your body differently to the long chain fatty acids found in other fats. They actually end up being a good source of energy and ketones which can help with some brain disorders like epilepsy or Alzheimers.

The energy that comes from the MCTs can also make you burn calories quicker and help with your weight over the long term.  At the same time, the ketones can reduce your appetite causing you to eat less, thus increasing any weight loss.  Even better, it seems the weight loss is often centered on belly fat which is one of the highest risk factors for heart problems. Combined with the increase in HDL and the reduction of LDL cholesterols, your arteries are better protected.

Coconut oil is definitely proving to be a true “super-food” and has a multitude of other benefits and uses. Make sure you buy organic or extra virgin oil though, as the refined oils will not have the same chemical make-up. You can use it for cooking at a high heat, baking, salad dressings, sauces, coffee creamer, to make healthy snacks and as a replacement for butter or other oils. You can also use it as a beauty treatment for your skin or hair.

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12. Orange Juice

Orange juice is an easy and simple addition to make your diet more heart-healthy – if it isn’t on your regular diet already.  Orange juice is the classic source of Vitamin C and provides a range of nutrients and anti-oxidants, such as potassium, folate, and thiamine. In particular, an antioxidant in orange juice called hesperidin is a flavonoid compound which improves the health of the delicate endothelial cells that line blood vessels and thus prevent heart attacks and strokes.

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Make sure that you choose complete, fresh orange juice with no added sugar, for best results.  Of course, orange juice contains many other healthful nutrients. Try and buy the juice which retains the pulp, as this contains the fiber which has its own benefits.  In fact, include actual citrus fruits in your diet whenever you can. Orange juice is also a good source of potassium, calcium, and magnesium, which are good for lowering blood pressure levels.

Orange juice has lower sugar levels and higher nutrient levels than most other juices, which supports its broad health benefits. The many other health benefits of oranges combine to make for a generally healthier body which will relieve the heart of the need to strain. Several studies have reported that orange juice intake had beneficial impacts on various markers of oxidative stress and inflammation which can damage your health, including heart health.

Some of these benefits include a stronger immune system, stronger, bones, better brain-cell health, improved collagen production for healthier skin, while the Vitamin C helps the body absorb iron, which in its turn helps the blood absorb oxygen – a key factor in helping your heart.  Thus, washing your iron tablet down with a glass of orange juice will help it to be absorbed quicker. However, drink orange juice in moderation. A single glass of orange juice in the morning is adequate.

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13. Spirulina

You probably don’t spend much time worrying that you may not be getting enough freshwater blue-green algae in your diet, but we hope to change that.  Given that most of us don’t follow the healthiest of diets, there is space on this list for a natural supplement that can boost your intake of the right nutrients.  Spirulina is basically pond scum, a natural “algae”, high in protein, antioxidants, and B-Vitamins, but is dried and completely safe to eat when you buy it in shops.

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Its cousin Chlorella shares most of the same benefits, but it sounds too similar to the disease to recommend it.  However, if it’s on special in the health food aisle, go for it. Spirulina has a broad range of health benefits.  With regard to the heart, it helps reduce blood pressure problems and repairs the endothelial cells which line the blood vessels and are easily damaged.  It will also reduce the levels of LDL cholesterol and triglycerides in the blood.

Its ability to clean up clogged arteries means that the risk of a stroke is also reduced. Nutrient-dense, protein-rich (it is 70% protein by weight), foods like spirulina take more energy to metabolize, and will, therefore, help reduce weight.  It also seems to reduce hunger pangs, particularly among overweight people. It extracts sugar from your cells, boosting your energy levels, and may also repair brain cell damage, improve memory and general cognitive function.

Other benefits include its ability to extract dangerous heavy metals from our bodies. While Westerners may worry about absorbing mercury from fish, Asians are often troubled by arsenic found in river water. It also helps balance the microbiome in the gut, thereby combatting thrush and similar infections and works to lower blood sugar levels. As always, speak to your doctor before adding supplements to your diet, and make sure you buy high-quality supplements from a reputable supplier.

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14. Whole Grains

Carbohydrates are generally considered a bad dietary choice these days, but that is usually because we are eating the bad ones where the goodness has been refined out of the food.  Fibre is an important component of a heart-healthy diet, but most people only eat half of the required daily amount.  Fibre mainly comes from whole grains and vegetables and fruit, and everyone knows we are not eating enough veggies and fruit.

So don’t leave the carbs out of your diet – just make sure at least half of them are the good ones.  Fibre helps the heart by removing bad cholesterol from the body and can also reduce blood pressure problems. Switching to high-fiber substitutes from refined grains is an easy choice to make, so replace your cereal with a high fiber alternative and wholewheat pasta, brown bread and brown rice instead.

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Since brown bread is man-made, spend some time shopping for a bread that has the best fiber load and watches out for added ingredients like extra sugar and salt which may detract from the health benefits of the product.  It may not be called “brown bread” but with a little effort you can find something that you enjoy but still offers whole grain health benefits.

Fibre can help you feel full but passes through your body undigested, indeed it can extract certain foods along the way; which means that it adds no calories and can actually reduce your calories.  The fiber in whole grains is usually of the insoluble variety, which means you should ensure you have oats, beans, and legumes in your diet to provide soluble fiber, which is the other useful type.  Make sure you drink lots of water to complement your fiber intake.

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15. Green Tea

Green tea is another easy substitute to make in your diet with great heart-health benefits.  Green tea is a refreshing, light aromatic tea which can reduce LDL cholesterol and triglycerides levels.  Green tea contains polyphenols such as catechins and flavonoids – these are the antioxidants that give green tea its greatest health benefits. Green tea drinkers can reduce their risk of cardiovascular disease by 30%!

While the catechins are available as a separate health supplement, drinking green tea bring a number of extra health benefits as well. One of the more powerful compounds in green tea is the antioxidant called Epigallocatechin Gallate (EGCG), which has been studied to treat various diseases and may be one of the main reasons green tea has such powerful medicinal properties.   Green tea also contains caffeine, although less than in coffee, which is a stimulant.

Caffeine, in combination with the amino acid L-theanine which is also in green tea, helps improve brain function. It can also slow down the impact of aging on brain neurons, in particular, fighting off diseases like Alzheimer’s. Small studies have shown that green tea can increase the body’s metabolic rate, thus burning more energy and producing weight loss. The many anti-oxidants and nutrients in green tea attack free radicals in the body, helping defend the body against various types of cancers.

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The same catechins which are such powerful antioxidants also have antibacterial properties and are particularly helpful in keeping mouth bacteria under control and reducing tooth decay and bad breath. By improving insulin sensitivity and reducing blood sugar levels, green tea helps people with diabetes or who are high risk for diabetes.  The overall benefits of green tea – indeed all the foods listed here – mean that it can contribute to a longer and healthier life.

16. Foods Fortified by Plant Sterols

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The term phytosterols include both plant sterols and plant stanols. Both are chemicals that occur naturally in plants. They have no taste or odor, so it’s easy for manufacturers to fortify foods with them. The original flavor of the food won’t be affected by the fortification. They work because their structure is the same as that as cholesterol. That means that they compete with cholesterol for the opportunity to be absorbed in the intestine. And they tend to be victorious. They are absorbed instead of the cholesterol. They don’t cause the same harm that cholesterol does. So, when your body absorbs them instead of cholesterol, your arteries can’t get clogged.

Studies conducted have shown that consuming foods fortified with plant sterols and stanols does lower the levels of cholesterol in the body. But you need to eat them every day to take advantage of their benefits. Foods fortified with plant sterols and stanols include wholegrain bread and cereals, rice and pasta, and reduced-fat dairy products.

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17. Turmeric

Turmeric is traditionally used in Indian cooking. It gives curries their yellowish color. Not only is it tasty, but it also creates a pleasing aesthetic when you use it in your cooking. But, even more importantly, it has a variety of healing properties. Its active ingredient is curcumin. This substance is rich in antioxidants. They stop fatty deposits from building up in your arteries before they even start. Some study has been done on turmeric and its effect on the health of your arteries. Mice were the subjects of the study. After 16 weeks, those mice fed a diet rich in curcumin had a 26% reduction in fatty deposits in their arteries. This means that curcumin may prevent the development of atherosclerosis.

The anti-inflammatory properties of turmeric can help to reduce the damage clogging does to your arteries. If you’re not a curry fan, you can still get turmeric into your diet. Try out a golden latte. It’s a beverage made with a healthy sprinkling of turmeric.

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18. Persimmons

A persimmon is a fruit that looks like a large tomato. Its flesh is sweet which makes it highly favorable to the palate. You can eat them as they are or include them in salads and baked pies and cakes. They are produced in China, Korea, and Japan. However, they are also grown in Southern Europe, Britain, and America.

Persimmons reduce LDL levels. These low-density lipoproteins are the so-called bad cholesterol. Left unchecked, high levels of LDL can clog up your arteries, making you a heart attack waiting to happen. Persimmons also reduce triglycerides. Triglycerides are lipids (fats) found in your body. They are formed in the body when it converts calories it doesn’t require into straight away into triglycerides. The fewer fats you have stored in your body, the less likely they are to clog up your arteries. Persimmons are full of antioxidants and polyphenols. There is also fiber present which clears the arteries and regulates the blood pressure.

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19. Cinnamon

Cinnamon is an inexpensive yet effective way to treat heart diseases such as clogged arteries. Studies into its efficacy show that cinnamon can have a positive effect on your heart. Cinnamon is full of antioxidants. They prevent oxidative stress. The oxidation process can lead to free radicals affecting the blood cells and damaging blood vessels such as the coronary arteries. These free radicals can do a lot of damage to the body and may even cause some forms of cancer.

During research, rats were fed a cinnamon diet. When their blood was studied, it was found to contain higher levels of antioxidants. The main component of cinnamon is called cinnamaldehyde. It has been studied for its capacity for preventing the formation of blood clots and reducing platelet aggregation. Platelet aggregation can cause blood clots to form in the arteries. Cinnamon is also a rich source of calcium, manganese, and fiber. These help with the production of bile which is made possible by the breakdown of cholesterol.

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20. Cranberries

The cranberry is often underrated and estimated. But it is proof that dynamite does come in small packages. These little berries of full of amazing compounds that are good for your overall health and well-being. Research indicates that cranberries are full of phytonutrients. These, in turn, contain polyphenols. Polyphenols have a vascular impact. They improve the health of your blood vessels.

A study conducted on 10 men showed growing improvements in their circulation, arterial rigidity, and blood pressure. The men had to drink just under 2 cups of sweetened cranberry juice diluted at different ratios with water. Even the cranberry juice mixed with other fruit juice such as that you can buy at the grocery store made a difference. This juice usually has a 25-27% cranberry juice content. Other studies have shown that cranberry sauce is equally beneficial. The research shows that it is a good idea to include cranberries in your diet. But you need to use them in combination with other remedies to unclog your arteries.

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21. Cheese

You would think that cheese would be a big culprit in the clogging up of your arteries. This is not necessarily the case. It’s possible that cheese could lower your blood pressure. This is good news. High blood pressure increases the rate at which arterial plaque builds up in the arteries. It also speeds up the hardening of the clogs in the arteries. High blood pressure is a warning sign that your arteries may be clogged. It could put you at risk of a heart attack.

A recent study conducted by researchers at the Brigham and Women’s Hospital and Harvard Medical School saw some surprising results when it comes to cheese. Those that ate three daily servings of low-fat dairy have lower blood pressure than those who do not. But readers should note the keyword here: low-fat. It is essential to read the labels when you buy dairy products to make sure they’re low-fat. Otherwise, you’ll be adding to your problems with clogged arteries instead of solving them.

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22. Watermelon

There’s nothing to beat a delicious slice of watermelon on a hot summer’s day. It’s sweet and refreshing. It’s the perfect base for a fruit salad. Or you can enjoy some own its own. Not only that, it’s an excellent diet food. Watermelon is recommended for people who want to lose weight. In addition to this benefit of watermelon, it can assist in the protection of your heart as well. It contains an amino acid called L-citrulline.

A study conducted at Florida State University studied people who were given a 4,000mg dose of L-citrulline. After a mere six weeks, their blood pressure had declined. It’s believed that the amino acids in watermelon help the body produce nitric oxide. This substance widens the blood vessels, allowing the blood to flow to the heart more easily. It also decreases the rate at which plaque grows in the arteries and prevents blood clots from forming. People with pre-existing heart conditions take nitroglycerin. It works by converting into nitric oxide.

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23. Spinach

There are so many benefits to including spinach in your diet. It is a rich source of vitamins and minerals. All leafy green vegetables are good for you, and spinach is no exception. Two of the most important substances we get from spinach are potassium and folate. These two substances are believed to your blood pressure which puts less strain on the arteries.

One of the most important things to remember with spinach is that cooking it removes a lot of the vitamins and minerals it contains. That’s why it’s a good idea to steam it gently or eat it raw. It might not suit everyone’s palate to each spinach this way. But raw spinach in a smoothie with some chocolate-flavored protein powder is the ideal way to get your daily portion. You can also include it in salads or serve it as an omelet filling. A single serving of leafy green vegetables like spinach each day can reduce your risk of developing heart disease by up to 11%.

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24. Lentils

Lentils contain a protein and fiber punch that your body needs to stay healthy. The lentil is a member of the legume family of vegetables. This includes beans and peas. Lentils grow in pods. You can get green, red, brown, and black lentils. They contain high amounts of folate and manganese. That’s why lentils are essential in reducing your risk of heart disease and other conditions such as obesity and diabetes.

The fiber in lentils reduces the LDL levels in the body. These ‘bad cholesterol’ levels can cause your arteries to clog up. The potassium, magnesium, and calcium in lentils are thought to reduce your blood pressure. You can substitute meat with lentils if you have really high cholesterol levels and you need to make radical changes to your diet. Another attractive factor about lentils is that they are inexpensive and easy to cook. They can also be incorporated into stews and soups to add fiber and flavor. And they help to ensure your arteries don’t get clogged up.

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25. Beans

Beans come in various forms. Among others, you get great northern beans, fava beans, kidney beans, navy beans, pinto beans, black beans, and chickpeas. Contrary to its name, the chickpea is a bean. It’s also known as the garbanzo bean. And let’s not forget the good old baked bean in tomato sauce. All of them are extremely healthy for you as they contain a lot of protein and soluble fiber.

The protein found in beans is essential for the unclogging of your arteries. Proteins contain all the amino acids your body needs. They are the building blocks of all the cells in your body. They also help to reduce the build-up of plaque in the arteries. Soluble fiber binds to your body’s bile salts which ensures your body doesn’t reabsorb them. It keeps blood sugar spikes under control. These episodes increase the amount of cholesterol in your body. The reason for this is that a blood sugar spike causes the liver to produce more cholesterol.

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26. Spices and herbs

To unclog your arteries, you can do something as simple as adding spices and herbs to your diet. Not only are they good for you, but they also add a special flavor to a meal and make it taste better. Spices and herbs are harvested from plants. These plants are able to protect their own cells from pests, etc. When the plant is converted into an herb or spice, it still has those protective powers. Except now, it’s protecting the cells of your body.

Examples of spices you should keep in your home and use in your cooking are plentiful. Here are just a few: Garlic improves cholesterol and lowers blood pressure. Both of these properties reduce your risk of heart disease. Turmeric’s main ingredient is curcumin. This spice reduces your cholesterol and triglyceride levels as well as your blood sugar. Ginger has anti-inflammatory properties that thin the blood, preventing clots. Cinnamon improves your circulation and keeps your blood sugar under control. Other examples include nutmeg, allspice, nutmeg, and Italian seasoning.

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27. Chia Seeds

The chia seed is a plant-based food that has the highest concentration of Omega-3 oils. It contains more than salmon, which is widely believed to be the best source of Omega-3 fatty acids. They are also rich in calcium. In fact, they contain more calcium than milk. They also contain more magnesium than broccoli. And the fact that they’re packed with magnesium is also important for your overall health and well-being.

Chia seeds contain a lot of soluble fiber. Soluble fiber is important in the fight against cholesterol. Your liver makes bile acid to digest foods. It needs cholesterol to make bile acid. Eating soluble fiber stimulates the need for bile acid. So, by eating foods such as chia seeds, you increase the need for bile acid and reduce cholesterol levels. The best part about chia seeds is that you can include them in just about any dish you serve as they have no taste. So, they won’t affect the flavor of your cooking.

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28. Tomatoes

If you’ve ever wondered why tomatoes are red, here’s your answer. They contain an antioxidant called proteinoid lycopene. It’s also found in green tomatoes or light red tomatoes as well. A diet that contains a lot of lycopene can lower the oxidation of bad cholesterol in your body. Bad cholesterol is what clogs up your arteries and causes atherosclerosis. It is the LDL cholesterol we must avoid. It also reduces the build-up of plaque in your arteries.

When we’re told about the important components in fruits and vegetables that are good for us, we’re told cooking them reduces the goodness. With tomatoes, this is not true. Their lycopene levels are stronger in tomatoes that have been cooked. In addition to the powerful antioxidant lycopene, tomatoes contain high levels of Vitamin A and C, as well as folic acid and beta-carotene. Tomatoes have anti-inflammatory properties which can lower the risk of heart disease. Increased inflammation in the arteries can lead to their susceptibility to becoming clogged.

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29. Apples

An apple a day keeps the doctor away, the saying goes. And it appears that it’s more than an adage, it’s the truth. Researchers at Ohio State University discovered that eating an apple a day reduced the hardening of arteries up to 40%. The magic ingredient in apples that makes it great for unclogging your arteries is called pectin. It gives the fruit its firmness, which allows us to enjoy a crisp apple. Pectin is a complex substance. It contains polysaccharides and a sugar residue called D-galacturonic acid.

Pectin seems to lower the levels of cholesterol in the body. It contains a lot of insoluble fiber. For this fiber to be digested, it needs bile acid. To make bile acid, the liver uses cholesterol. The more cholesterol used to digest insoluble fiber, the less there is to clog up your arteries. The LDL levels are lowered in the body when insoluble fiber such as that in apples is introduced to the digestive system.

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30. Flaxseeds

A study conducted and published in the American Journal of Physiology and Circulation Research looked at the effects of flaxseeds on rabbits. They found that introducing flaxseed into the rabbits’ diet slowed down the progression of atherosclerosis. This is the build-up of plaque in the arteries which can cause the blockage or constriction of an artery. This results in a heart attack. It’s not yet clear though if flaxseeds can reduce the build-up of plaque in the arteries that has already accumulated.

Flaxseeds are a source of Omega-3 fatty acids. This is essential to the metabolic process. It is not produced in the body and needs to be obtained from food sources. The soluble fiber in flaxseed is important as it stimulates the production of bile acids which help to expel waste from the body. There are lots of ways to include flaxseed in your diet. You can buy it ground to a fine powder. This can be included in a bowl of cereal or oatmeal.

 

MedicalNews

 

#El #cierre de la orejuela ‘abre la puerta’ a la prevención del #ictus por #fibrilación auricular

Postado em Atualizado em

Hasta el 95% de los ictus secundarios a disfunción arrítmica se originan en esta zona, por lo que la técnica del cierre de la orejuela, en los casos indicados, es una opción eficaz.

Luis Nombela, Pilar Jiménez y Pablo Salinas, del Hospital Clínico de Madrid.
Hospital Clínico de Madrid

El cierre de la orejuela izquierda, estructura muscular del corazón localizada en la aurícula, es una buena opción para pacientes con fibrilación auricular (FA), patología que eleva significativamente sus posibilidades de sufrir un ictus. Se trata, por tanto, de “un procedimiento intervencionista todavía poco conocido, pero con demanda asistencial creciente”, indica Pablo Salinas, de la Unidad de Hemodinámica del Servicio de Cardiología, englobado en el Instituto de Investigación Cardiovascular, del Hospital Clínico de Madrid, centro pionero en la realización de esta técnica con la que acaba de alcanzar las cien intervenciones.

El interés por extender el cierre de la orejuela se sustenta en datos: entre el 1 y el 2% de la población tiene fibrilación auricular (FA), la arritmia más común y cuya frecuencia aumenta a medida que la población envejece: por encima de los 75-80 años, esta cardiopatía aparece en un 5% de las personas. “El progresivo envejecimiento de la población hace prever que la FA aumentará de forma paralela”, sin olvidar además que conlleva un riesgo aumentado de ictus: de hasta cinco veces más que el que presenta la población general. Pero, ¿cuál es el papel de la orejuela en todo este entramado de cifras? Salinas responde que “se considera que entre el 90-95% de los ictus por FA se originan por trombos en la orejuela izquierda”, por lo que actuar sobre esta zona sería esencial.

Una de cada tres personas anticoagulada con FA y riesgo
de ictus no tolera la medicación por el desarrollo de sangrados

El razonamiento de actuación es de mayor alcance, según el cardiólogo. La anticoagulación es el tratamiento de elección para la mayoría de los pacientes con FA y riesgo de ictus, bien con Sintrom o más recientemente con los anticoagulantes directos. Sin embargo, y según recogen datos de diversos estudios y de la práctica clínica, con ambas terapias, “una de cada tres personas no tolera la anticoagulación prescrita, básicamente por sangrados digestivos, y asociado a comorbilidades. Con los anticoagulantes directos, el sangrado craneal se reduce significativamente, pero otros, como el digestivo no”.

Esta situación representa una dicotomía para profesionales y pacientes: emplear sí o no medicación para reducir el riesgo de ictus, pero manteniendo el de sangrado. Así, el cierre de la orejuela aparece como una opción con unas indicaciones concretas.

En Estados Unidos, por ejemplo, la técnica se contempla como alternativa a la eliminación de anticoagulantes. En Europa se indica en personas anticoaguladas, pero con contraindicaciones o no tolerancia a anticoagulantes, fundamentalmente por sangrado, tal y como se ha llevado a cabo en el 90% de los candidatos del Hospital Clínico. El tercer escenario es el de pacientes que, a pesar de estar anticoagulados, siguen teniendo ictus, lo que obliga a cerrar la orejuela, pero manteniendo la anticoagulación.

 

Dispositivo que tapona la entrada de la orejuela izquierda, relacionada con el desarrollo de ictus por fibrilación auricular.

Dispositivo que tapona la entrada de la orejuela izquierda, relacionada con el desarrollo de ictus por fibrilación auricular.

Para Salinas, otra de las ventajas de esta práctica es que, una vez que se ocluye la orejuela, “se puede bajar un escalón terapéutico: de la anticoagulación a la antiagregación, estrategia que disminuye la posibilidad de hemorragias. En algunos pacientes, pasado un tiempo y según el riesgo de sangrado, es posible retirar incluso la antiagregación”.

Bajar un escalón terapéutico, otra ventaja

La eficacia del procedimiento, en el caso de FA e intolerancia a anticoagulación, es elevada y puede considerarse una buena estrategia para eliminar el riesgo aumentado de ictus, subraya Salinas, quien añade otra ventaja: cuando se cierra la orejuela, la anticoagulación se elimina, lo que también es una medida coste-eficaz. “El mantenimiento con antiagregantes, que suelen ser bien tolerados, estos pacientes tienen una tasa de ictus similar a la de la población general”.

Los cien pacientes que ha intervenido el equipo del Clínico tenían una edad media de 76 años. La mitad ya había sufrido un ictus y el 85 % hemorragias -algunos hasta dos-, cifras que reflejan que “los pacientes llegan tarde; ya han tenido hemorragias, digestivas, seguidas de las intracraneales, y otras complicaciones”. Además, si estos pacientes no son tratados, “la tasa teórica de ictus podría ser de entre un 8-11% anual. Con el cierre de la orejuela este porcentaje se reduce al 1,6% anual, similar al  de la población general, según los datos de nuestra serie”.

Si los pacientes no son tratados, la tasa teórica anual de ictus se situaría en torno a un 8-11%. El cierre de la orejuela consigue que este porcentaje disminuya al 1,6% anual, similar al de la población general

El seguimiento a medio plazo -unos dos años-, ha demostrado también que el 95% de los intervenidos deja de tomar anticoagulantes y que el 80% se mantiene con un antiagregante. Un 15% se mantiene sin medicación. Salinas aclara que esta bajada de escalón terapéutico es, a veces, motivo de debate médico “Es cierto que no en todos los casos se retira la medicación sino que se reduce la potencia del tratamiento al cambiar el anticoagulante por el antiagregante, lo que se traduce en menor posibilidad de sangrado sin dejar de proteger contra el ictus, que es básico”.

Tarea de todos

Salinas insiste en la importancia de una adecuada derivación de pacientes para que se beneficien de esta estrategia para lo cual se necesita la implicación de geriatras, hematólogos, neurólogos, digestivos e internistas, entre otros. Desde hace año y medio, el equipo del Clínico forma parte de CardioRed, una alianza en la que participan los hospitales de Fuenlabrada, Príncipe de Asturias, en Alcalá de Henares; y Severo Ochoa, en Leganés, que cubren un área asistencial cercana al millón de personas.

Entre sus objetivos está el que otros profesionales conozcan esta posibilidad que “se hace mucho menos de lo que probablemente estaría indicado. Los cardiólogos prescribimos la medicación, pero los efectos adversos, como los sangrados, se abordan desde otras especialidades”.
De hecho, se estima que la técnica sólo se está aplicando actualmente en un 10% del total de potenciales candidatos, cuando este procedimiento, más que terapéutico, es preventivo”.

¿Cómo se realiza el procedimiento?

El procedimiento se basa en cerrar una estructura de la aurícula izquierda, la orejuela, que se asemeja a una manga de viento. Su función y utilidad concretas no están bien definidas. Lo único claro es que es posible vivir sin orejuela y que cuando existe FA puede ser una fuente de problemas, ya que deja de contraerse, provocando que la sangre se remanse dentro de ella y dando lugar a coágulos sanguíneos que suelen ser responsables directos del desarrollo de un ictus.

Para cerrar o ocluir esta cavidad se ha diseñado un dispositivo, similar a un tapón, que consigue que la superficie quede lisa. De forma intervencionista, el procedimiento consiste en la introducción de un catéter por la vena femoral  -lo que hace la técnica más segura al no tratarse de una arteria- de la ingle hasta alcanzar y atravesar el septo interauricular -pasando del lado derecho al izquierdo-.

El trayecto se completa en el orificio de entrada de la orejuela desde donde se implanta y libera el dispositivo que va unido al catéter y que tapona la orejuela. El proceso se realiza con ecografía transesofágica, control que otorga una seguridad muy elevada. Se realiza con sedación o con anestesia general, en función de las necesidades médicas.

Que antitrombótico usar em paciente com doença arterial obstrutiva periférica?

Postado em Atualizado em

Eduardo Sansolo
Escrito por Eduardo Sansolo
A Doença Arterial Obstrutiva Periférica (DAOP) é a terceira mais prevalente manifestação da aterosclerose atrás apenas da doença coronariana e cerebrovascular. Está presente em mais de 200 milhões de pessoas no mundo e é uma causa significativa de morbidade e mortalidade devido à perda do membro. Apesar da terapia antitrombótica ser parte importante do tratamento para prevenção de eventos cardiovasculares, os pacientes com DAOP são frequentemente subtratados. Além disso, há poucos estudos duplo-cegos, randomizados com tratamento clínico dos pacientes com DAOP, dificultando a uniformização de práticas clínicas e guidelines. É nesse contexto que visamos a resumir as evidências disponíveis sobre os agentes antitrombóticos no tratamento da DAOP.

O estreitamento devido à aterosclerose da aorta infra-renal e das artérias dos membros inferiores é a principal causa da DAOP e a ativação plaquetária desempenha papel importante no surgimento e agravamento dessas lesões. Do ponto de vista da decisão clínica, os pacientes portadores de DAOP devem ser divididos em 3 grandes grupos:

  • Assintomáticos;
  • Sintomáticos;
  • Revascularizados

Baseado nesta divisão, seguem os principais estudos com evidência de antitrombóticos em DAOP(Fig 1):

 

Pacientes assintomáticos

Atualmente, não há evidência da eficácia de aspirina em pacientes portadores de DAOP assintomáticos, entretanto dado o risco aumentado de eventos cardiovasculares, o tratamento com AAS em pacientes assintomáticos é sensato, particularmente se há evidência de doença aterosclerótica em outros leitos arteriais.

Pacientes sintomáticos

Pacientes com DAOP sintomática devem ser tratados com agentes antitrombóticos a fim de reduzir o risco cardiovascular. O uso em esquema de monoterapia de AAS ou clopidogrel é recomendado, embora estudos robustos de pacientes com DAOP sejam limitados e as inferências feitas através de análise de subgrupos de estudos cardiovasculares. Estes estudos demonstram uma redução de 1,5% ao ano de complicações vasculares sérias com o uso de AAS em pacientes portadores de DAOP sintomática. Logo, apesar da fraca evidência, o uso de AAS em monoterapia deve ser encorajado em pacientes com DAOP sintomática.

Outros agentes também foram estudados como prevenção secundária. O estudo CAPRIE demonstrou um benefício do clopidogrel sobre o AAS em pacientes com DAOP demonstrando uma redução anual de 1,15% em eventos vasculares. Já o COMPASS evidenciou que o uso de Rivaroxaban associado ao AAS reduziu 1,54% ao ano o risco de amputação de membros em pacientes sintomáticos. Entretanto, estes benefícios devem ser ponderados, uma vez que há o aumento de risco de sangramento de 0,69% ao ano.

Pacientes portadores de DAOP com história recente de angioplastia coronariana ou evento coronariano agudo devem receber duplas antiagregação com AAS + Clopidogrel ou AAS + Ticagrelor. O uso de dois antiagregantes a longo prazo deve ser não é isento de riscos, uma vez que aumenta a chance de eventos hemorrágicos em 2 vezes se comparada com o uso de monoterapia com AAS.

Pacientes revascularizados

Pacientes submetidos à revascularização dos membros inferiores devem receber terapia antitrombótica continuamente. No subgrupo submetido à cirurgia convencional, tanto o AAS quanto o Clopidogrel ou a associação de Rivaroxaban com AAS apresentam benefícios. Nos pacientes cirúrgicos de risco baixo e intermediário de perda do membro a monoterapia com AAS ou Clopidogrel está bem indicada. Já nos do subgrupo de mais alto risco de perda do membro, tais como bypass com prótese, bypass para vasos da perna, desague pobre,  a associação Rivaroxaban + AAS deve ser prescrita. A terapia tripla com 2 antiagregantes + anticoagulação deve ser evitada devido ao risco proibitivo de eventos hemorrágicos.

Nos pacientes submetidos ao tratamento endivascular, a terapia padrão de dupla antiagregação com AAS + Clopidogrel por 1 a 6 meses seguida de monoterapia contínua deve ser a indicada.

Abaixo segue um algoritmo para o auxílio à escolha clínica de manejo antitrombótico em pacientes com DAOP(Fig2).

Referências bibliográficas:

Mohamad A. Hussain, Mohammed Al-Omran, Mark Creager, Deepak L. Bhatt et al. Antithrombotic therapy for peripheral artery disease. Journal of the American College of Cardiology 2018; 71(21): 2381-2496.

#L’IRM est-elle le meilleur moyen pour évaluer l’ischémie et la viabilité ?

Postado em

Gilles BARONE-ROCHETTE, cardiologie interventionnelle et imagerie cardiaque – UMR INSERM – 1039 ; FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network ; Service universitaire de Cardiologie/Pôle Thorax et Vaisseaux, CHU de Grenoble

L’IRM cardiaque tient de plus en plus de place dans la prise en charge de nos patients. Ses performances importantes dans les différents domaines de la cardiologie sont attestées par de nombreuses publications. Dans le domaine de la cardiopathie ischémique, les recommandations européennes classent l’« IRM de stress » en rang IA pour le dépistage de la maladie coronaire chez les patients avec une probabilité prétest intermédiaire. Par les principes physiques qui sont utilisés pour acquérir les images, elle présente plusieurs avantages. Elle permet en effet, lors d’un même examen, d’avoir des informations anatomiques proches du scanner pour la résolution spatiale, une étude de la fonction globale et segmentaire ventriculaire ainsi que la mesure des volumes, des masses et des fractions d’éjection droites et gauches où elle est la référence. Enfin l’injection de chélates de gadolinium permet à la fois une étude de la perfusion, mais aussi une caractérisation tissulaire myocardique non invasive qui est la seule corrélée à l’analyse histologique. Ces dernières séquences dites de rehaussement tardif permettent entre autres, une étude de la viabilité dans le cadre de la cardiopathie ischémique. Avec toutes ses informations et possibilités lors d’un même examen, on peut se demander si l’IRM est le meilleur moyen pour évaluer l’ischémie et la viabilité.

Comme souvent en médecine, la réponse ne peut pas être un oui ou un non catégorique et nous allons voir que les données de la littérature et l’expérience sur le terrain permettent de répondre à cette question de manière plus nuancée.

Pour le diagnostic de la maladie coronaire

L’IRM cardiaque permet donc de dépister l’ischémie myocardique soit par l’imagerie de la perfusion myocardique au cours du stress pharmacologique (adénosine ou dipyridamole et pour certains centres en Europe le régadénoson), soit par l’imagerie de la fonction ventriculaire lors d’une perfusion de doses croissantes de dobutamine-atropine à la recherche d’anomalie de la cinétique segmentaire exactement sur le même principe que l’échographie sous dobutamine-atropine.

En pratique c’est surtout l’IRM de perfusion sous stress pharmacologique (P-CMR) qui est réalisée.

Il a été en effet montré que chez un patient échogène, l’IRM sous dobutamine-atropine n’était pas plus performante que l’échographie de stress(1). De plus celle-ci est plus difficile à mettre en place en pratique. Rappelons rapidement le principe de la P-CMR. Les chélates de gadolinium donnent un hyper-signal qui permet grâce à des séquences dynamiques rapides de voir arriver le produit de contraste d’abord dans le ventricule droit, puis le gauche puis l’arrivée dans le myocarde où le gadolinium donnera un hyper-signal dans les zones bien perfusées.

Une sténose coronaire va entraîner un défaut d’« arrivage » du gadolinium dans le myocarde apparaissant comme un hyposignal au niveau du sous-endocarde qui sera présent sous stress et non au repos (figure 1).





Figure 1. Cinétique d’arrivée du chélate de gadolinium après injection intraveineuse.
*Hyposignal sous-endocardique signant une ischémie.

Dans tous les cas, la réalisation de l’IRM de perfusion ou sous dobutamine demande la même organisation que tous les tests d’ischémie. À savoir, la vérification de la non-prise de caféine ou autres bases xanthiques dans les 24 heures avant l’examen si on utilise l’adénosine, le dipyridamole ou le régadénoson, la vérification des contre-indications à l’examen, un ECG avant et après la procédure, la constitution d’une équipe associant cardiologue spécialiste de la maladie coronaire de préférence et radiologue avec la mise en place d’une procédure d’évacuation et de réanimation (chariot de réanimation, défibrillateur), au mieux un scope ainsi qu’un injecteur amagnétique.
Les bonnes performances de la P-CMR sont démontrées lors de plusieurs métaanalyses. D’abord face à la coronarographie(2), mais plus récemment face à la FFR où sur les deux dernières métaanalyses publiées, les résultats les plus performants dans le diagnostic étaient pour la P-CMR(3,4) face aux autres techniques. Ces résultats sont probablement explicables par la résolution spéciale très bonne de l’examen lui permettant d’avoir un avantage, notamment dans le cadre des patients pluritronculaires sur les autres examens de recherche d’ischémie. Il va sans dire que bien sûr s’agissant de métaanalyses d’études publiées dans un domaine très spécifique, notamment quand on se compare à la FFR, que nous avons affaire à des équipes expérimentées. Il faut en effet une certaine expérience de l’équipe, comme tout examen complémentaire, pour la réalisation de P-CMR de qualité.

L’évaluation de la viabilité dans le même temps

La recherche de viabilité est encore discutée dans le cadre de la cardiopathie ischémique avec altération de la fraction d’éjection où se pose la question de la revascularisation puisque sa recherche est une recommandation de rang IIb dans les dernières recommandations européennes parues en 2018. Celle-ci peut être évaluée après l’injection des chélates de gadolinium qui ont été injectés pour étudier la perfusion.
Grâce à des séquences dédiées, dites de rehaussement tardif réalisées à 10 minutes de cette injection, les séquelles d’infarctus du myocarde vont pouvoir être étudiées.
Le gadolinium donnera un hypersignal débutant du sous-endocarde vers l’épicarde. En fonction de la transmuralité de la prise de contraste, on déterminera la viabilité du segment (figure 2). Les figures 3A et B montrent des exemples de protocoles d’acquisition couplant la recherche d’ischémie et de viabilité. Il a été démontré que la mise en évidence d’une séquelle ischémique améliorait les performances diagnostiques de la P-CMR. Le dépistage de petite séquelle d’infarctus invisible en scintigraphie myocardique (SPECT) et les autres techniques permettent de donner un avantage à la P-CMR encore dans le diagnostic de la maladie coronaire(5).




Figure 2. Schématisation du pourcentage de transmuralité pour un segment myocardique de la prise de contraste sur séquence de viabilité.


Figure 3. A. Protocole d’évaluation de la fonction, de l’ischémie et viabilité avec de l’adénosine. B. Protocole d’évaluation de la fonction, de l’ischémie et de la viabilité avec de la persantine.

Ainsi la recherche d’ischémie par P-CMR s’intègre dans un examen complet, permettant l’analyse fine de l’anatomie, la fonction ventriculaire et la viabilité myocardique.

Une évolution rapide

Comme nous l’avons vu, un puissant avantage de l’IRM cardiaque est la multitude de séquences possibles avec le même appareillage, séquences permettant la mesure de nombreux paramètres cardiaques. Mais non seulement des techniques utilisées pour certaines applications non coronaires vont être utilisées de manière intelligente pour obtenir des paramètres pronostiques de la cardiopathie ischémique, mais nous avons aussi de nouvelles séquences toujours plus performantes permettant de mesurer de nouveaux index. Donnons quelques exemples.

L’analyse des flux est possible en IRM grâce à des séquences dites en contraste de phase.

Elles sont particulièrement intéressantes pour mesurer le flux aortique et quantifier une insuffisance aortique où il existe un doute sur la sévérité de celle-ci avec les autres techniques d’évaluation. Dans le cadre de la cardiopathie ischémique une équipe a récemment utilisé cette mesure en contraste de phase pour quantifier le flux dans le sinus coronaire au repos et sous adénosine. Cela a permis d’obtenir une mesure de la réserve coronaire dont l’utilité pronostique vient d’être démontrée dans une très belle publication(6). Il existe aussi de nouvelles séquences comme le T1 mapping, dont on parle beaucoup pour la mesure de la fibrose diffuse, qui viennent de montrer un intérêt fort intéressant dans la caractérisation de l’ischémie myocardique due à une atteinte épicardique ou microcirculatoire coronaire. En effet dans cette étude la valeur diagnostique de l’utilisation du T1 mapping sous stress et au repos sans gadolinium était correcte face à une étude de la physiologie coronaire complète utilisant nos derniers index invasifs (FFR, CRF, IMR)(7). Cette technique apparaît très prometteuse.

Les limites

Il existe bien sûr des limites qui expliquent que l’on peut se demander si l’IRM cardiaque est le meilleur examen pour évaluer l’ischémie et la viabilité et que dans la pratique de la plupart des centres, l’IRM cardiaque n’est pas utilisée en priorité pour cette évaluation.

• La première des limites est bien sûr la disponibilité des machines. En effet les plages d’IRM cardiaque ne sont pas extensibles et il n’est pas possible dans la plupart des centres d’avoir une IRM dédiée cœur pour des contraintes administratives. Les plages d’IRM cardiaque se partagent donc avec toutes les disciplines où elle a aussi un intérêt indiscutable comme la neurologie entre autres. Dans le domaine de la cardiologie, ses indications explosent dans le domaine de l’évaluation des cardiomyopathies et dans certains centres pour l’évaluation valvulaire. Beaucoup de centres prioriseront donc l’IRM pour des indications où il n’y a pas d’alternatives (myocardites, cardiomyopathies…) et lorsqu’ils disposent d’autres tests d’ischémie (écho d’effort, SPECT, TEP) orienteront la majorité des patients pour évaluation coronaire vers ces tests. Comme nous l’avons vu aussi il faut une certaine organisation et une certaine expérience pour être performant en P-CMR qui n’est pas encore disponible dans tous les centres, limitant encore la disponibilité de la P-CMR.

• La fibrose systémique néphrogénique, notamment chez les patients avec une insuffisance rénale n’a pas été décrite avec tous les chélates de gadolinium, mais demande une surveillance des patients ayant bénéficié d’une injection de gadolinium.

• Il existe des contre-indications relatives comme la claustrophobie. Avec une préparation pharmacologique ou par hypnose conversationnelle, on peut parfois arriver à réaliser l’IRM chez ces patients. Les IRM à champ ouvert arrivent sur le marché, mais il n’y a pas de données quant à ses performances pour la P-CMR. Autre contre-indication relative, sont les porteurs de stimulateurs ou défibrillateurs. En effet, sous réserve d’une procédure en collaboration avec l’équipe de rythmologie, mais là encore cela demande une organisation. Cependant, les artefacts générés par le matériel selon leur position peuvent être gênants pour l’interprétation de l’IRM. Enfin des contreindications absolues persistent comme la Valve de Starr-Edwards à bille métallique, l’Anneau de Carpentier (4 400 et 4 500), les pompes à insuline, les clips vasculaires ferro-magnétiques, les implants oculaires et otologiques, les corps étrangers ferro-magnétiques (oculaires) et les neurostimulateurs.

Des limites pour l’évaluation de la maladie coronaire

Si l’IRM de perfusion dans une équipe entraînée offre des performances dans le diagnostic de la maladie coronaire remarquables, il faut avouer que pour la quantification de l’ischémie myocardique nous avons moins de données qu’avec la SPECT. Rappelons tout de même que les cut-offd’ischémie pronostique qui entraînent la réalisation d’une coronarographie en vue d’une revascularisation reposent sur des données observationnelles, notamment en SPECT(8), et nous attendons avec impatience les données de l’étude internationale ISCHEMIA (NCT01471522) pour obtenir des données issues d’un essai randomisé. Les données sur le seuil d’ischémie en P-CMR pour aller à la coronarographie reposent sur moins de données de la littérature(9), mais restent comparables à la SPECT (10 % du ventricule gauche).

Toujours pour cette évaluation de l’ischémie, il faut savoir que les séquences habituellement utilisées sont constituées de 3 coupes et peuvent offrir une couverture non optimale du ventricule gauche.

Cela peut entraîner une sousestimation de l’étendue de l’ischémie myocardique. De nouvelles séquences permettent une meilleure couverture du ventricule gauche et devraient être disponibles dans de plus en plus de centres. Pour la viabilité avec le cut-off de prise de contraste > 50 % de transmuralité sur un segment, seulement 10 % de ces segments récupéreront une contractilité après revascularisation. Mais lorsque le segment myocardique présentera une prise de contraste de 25 à 50 %, seulement 40 % récupéreront une contractilité après revascularisation(10). Ainsi il faudra savoir en fonction du contexte choisir les tests les plus sensibles ou spécifiques et savoir coupler les examens dans certains cas. Selon les cut-off choisis, la sensibilité et la spécificité du test pour la recherche de viabilité varieront.

Il faut retenir que les tests les plus sensibles pour la recherche de la viabilité sont la TEP et la SPECT utilisant le thallium redistribution à 4 heures(11). Et que les tests fonctionnels comme l’échographie sous dobutamine faible dose ou l’IRM sous dobutamine seront des tests plus spécifiques(12).

En pratique

  • Effectivement l’IRM cardiaque est très performante pour le diagnostic dans la maladie coronaire par le fait qu’avec un seul appareil et finalement un protocole bien conduit nous obtenions une masse importante d’informations.
  • Cependant, les performances d’un test d’imagerie dépendent avant tout des caractéristiques du patient (âge, échogénicité, probabilité Prétest), de la question médicale posée (évaluation diagnostique avec présence ou non de la maladie coronaire, évaluation pronostique par quantification de l’ischémie, choix d’un test plus sensible ou spécifique pour la viabilité), mais aussi de l’expérience locale et de l’organisation locale avec notamment la disponibilité des machines.
  • L’IRM pourra donc être le meilleur moyen pour évaluer l’ischémie et la viabilité selon ces paramètres pris en considération par le clinicien.

Références

1. Nagel E et al. Circulation 1999 ; 99 : 763-70.
2. Hamon M et al. J Cardiovasc Magn Reson 2010 ; 12 : 29.
3. Takx RA et al. Circ Cardiovasc Imaging 2015 ; 8.
4. Danad I et al. Eur Heart J 2017 ; 38 : 991-8.
5. Wagner A et al. Lancet 2003 ; 361 : 374-9.
6. Indorkar R et al. JACC Cardiovasc Imaging 2018 ; publication avancée en ligne le 22 octobre.
7. Liu A et al. J Am Coll Cardiol 2018 ; 71 : 957-68.
8. Hachamovitch R, et al. Eur Heart J 2011 ; 32 : 1012-24.
9. Schwitter J, Arai AE. EHJ 2011 ; 32 : 799-809.
10. Roes SD et al. Eur J Nucl Med Mol Imaging 2009 ; 36 : 594-601.
11. Schinkel AF et al. Curr Probl Cardiol 2007 ; 32 : 375-410.
12. Nagel E, Schuster A. Cardiovasc Imaging 2012 ; 5 : 509-12.

#Anticoagulantes orales directos: la opción para #trombosis en cáncer

Postado em

Nuevos tratamientos facilitan la prevención del evento trombótico en cáncer, complicación que ensombrece la evolución del paciente.

Infusion pump feeding IV drip into patients arm focus on needle

En un paciente con cáncer, la prioridad es controlar el tumor, ya que es el principal riesgo para su vida. Sin embargo, asociados a la enfermedad hay otra serie de riesgos que también deben vigilarse porque pueden acabar siendo la causa indirecta del fallecimiento. De esta forma, por ejemplo, la enfermedad tromboembólica venosa (ETV) es una de las complicaciones más frecuentes y la segunda causa de muerte prevenible en los pacientes oncológicos.

La última actualización de las guías clínicas para el tratamiento de la trombosis asociada al cáncer señala que el uso de los anticoagulantes orales directos debería ser a partir de ahora el tratamiento de primera línea. “En el estudio en el que hemos participado se ha visto que la trombosis venosa ocurre en el 20% de los pacientes y comprobamos que los nuevos anticoagulantes igualan los resultados de la heparina, que es el actual tratamiento de elección, en la prevención de las complicaciones trombóticas y su gran aportación es que disminuyen de manera muy significativa el riesgo de sangrado, excepto en los tumores gastrointestinales”, explica Amparo Santamaria, hematóloga y jefa de la Unidad de Trombosis del Hospital Universitario Valle de Hebrón, de Barcelona.

Limitar los riesgos

Los tumores producen sustancias procoagulantes que activan la coagulación. La cirugía, la quimioterapia, la colocación de catéteres o la inmovilización prolongada pueden inducir estados de hipercoagulabilidad y la formación de trombos. En algunos cánceres, como el de riñón, ovario, colon o sistema nervioso central (SNC), existe un mayor riesgo. La edad avanzada y el estadio del cáncer también son factores de riesgo que se deben tener en cuenta. Todo esto hace que en los pacientes oncológicos el riesgo de sufrir un evento tromboembólico sea hasta siete veces superior y que un 20% de los pacientes presenten un riesgo alto de hemorragia y de tromboembolismo recurrente.

La hemorragia y el tromboembolismo son siete veces superiores en enfermos oncológicos. También existe mayor riesgo de fibrilación auricular 

“Sin embargo, a pesar de saber todo esto, no se le está dando la importancia que tiene la anticoagulación en estos pacientes. Vemos cada vez más cómo se siguen administrando los mismos tratamientos y hay pacientes que llevan muchos años con heparina cuando sabes que lo que hay que hacer es manejarlos de forma diferente. No existen unidades especializadas en el manejo a largo plazo de estas complicaciones”, señala Santamaria.

Otra de las complicaciones asociadas es la fibrilación auricular, que en los pacientes de cáncer llega a ser de hasta el 4%, el doble de prevalencia que en la población general. “Esto puede deberse al mismo cáncer, que crea problemas en el corazón, pero sobre todo por los nuevos tratamientos contra dianas moleculares que consiguen mejorar la supervivencia, pero que tienen este efecto secundario”, explica la hematóloga, quien además señala cómo hace no mucho tiempo no se veían pacientes de cáncer con fibrilación auricular, una enfermedad que se suele asociar a la edad.

“Al cronificar la enfermedad estamos empezando a ver complicaciones nuevas, como estas fibrilaciones auriculares. Es una buena noticia, entre comillas, porque significa que estamos mejorando la supervivencia, pero que hace necesario que tengamos presentes estas nuevas comorbilidades para que no haya complicaciones con los pacientes”, apunta, e insiste en que con la terapia con anticoagulantes orales directos es posible un manejo seguro y que ayude a reducir muchos de estos riesgos.

“Aunque la primera causa de muerte sigue siendo el cáncer, la segunda es la coagulación. Estamos tratando muy bien al paciente con cáncer, pero estos nuevos fármacos están haciendo que haya un aumento de trombosis y problemas cardiológicos. Por eso, es necesario que el especialista determine cuál es el tratamiento más adecuado y así mejorar el pronóstico a largo plazo y la calidad de vida del paciente”.

No limitar por financiación

Uno de los factores que juegan más a favor de la utilización de los nuevos anticoagulantes directos orales es cómo ayudan en la adherencia terapéutica. “A pesar de que ahora mismo no está financiado por la Seguridad Social, los pacientes prefieren el tratamiento por vía oral. Tras varios meses con heparina muchos de ellos tienen molestias por los pinchazos y pueden saltarse alguna dosis”.

Aunque los pacientes de cáncer suelen ser en general muy cumplidores de sus tratamientos, también es cierto que no se debe olvidar la facilidad de la administración de los fármacos para ayudarles en este sentido. Por eso, la profesional considera que debería insistirse más en que estos nuevos anticoagulantes fueran financiados. “Una vez que se pueda disponer de esta opción, el paso siguiente sería concretar, de forma individualizada, cuál es el mejor tratamiento: o heparina o los nuevos anticoagulantes, en función de la situación de cada paciente. Pero debería quedar claro que su financiación o no por el sistema no debería ser el elemento determinante”, concluye.

 

Nuevas unidades para el control de la oncotrombosis

Las nuevas recomendaciones sobre terapia de la trombosis asociada al cáncer apoyan un enfoque multidisciplinar, de oncólogos y hematólogos, en unidades de Oncotrombosis con un objetivo: mejorar los resultados para los pacientes.

“Los afectados necesitan un manejo más exquisito y de precisión de los anticoagulantes, porque sus tratamientos van cambiando a lo largo de la enfermedad. La experiencia del hematólogo ayudaría en esta medicina más personalizada”, explica Amparo Santamaria, quien pone como ejemplo las unidades creadas en su momento de cardio-oncología para tratar la toxicidad cardiovascular de los tratamientos y los buenos resultados que se están obteniendo.

“El aumento de la supervivencia en cáncer hace necesario un enfoque más a largo plazo y un buen seguimiento por parte de especialistas dentro de estas unidades de onco-trombosis”.

#Psoriatic disease: #carotid ultrasound predicts #cardiovascular events

Postado em Atualizado em

  •  Univadis Medical News
  •  

Combining vascular imaging data with information on traditional cardiovascular risk factors could improve the accuracy of cardiovascular risk stratification in patients with psoriatic disease (PsD), according to a new research published in Arthritis & Rheumatology.

The cohort study included 559 adults with PsD who underwent ultrasound assessment of the carotid arteries at baseline between 2009 and 2015 to assess the burden of atherosclerosis. Information about cardiovascular risk factors was collected and used to calculate the expected cardiovascular risk using the Framingham Risk Score (FRS). Participants were followed until December 31, 2017.

A total of 23 patients experienced confirmed cardiovascular events (CVE). The rate of first CVE during the study period was 1.11 events per 100 patient years (95% CI 0.74-1.67). When analysed separately, total plaque area (TPA) (HR 3.74; 95% CI 1.55-8.85; P=.003), mean carotid intima media thickness (cIMT) (HR 1.21; 95% CI 1.03-1.42; P=.02), max cIMT (HR 1.11; 95% CI 1.01-1.22; P=.03) and high TPA category (HR 3.25; 95% 1.18-8.95; P=.02) predicted incident CVE after controlling for FRS.

“Our study suggests that ultrasound can also be used to identify patients that are at high cardiovascular risk who may be missed by the conventional methods such as the FRS,” said senior author Lihi Eder of the University of Toronto.

#Le diabétique : un coronarien comme les autres ?

Postado em

Louis POTIER, Paris, d’après Thomas CUISSET, Marseille

 

Particularités du coronarien diabétique : TTT antiplaquettaire et revascularisation

Lors de cette plénière d’introduction de cette cuvée 2019 du congrès de la Société francophone du diabète, Thomas Cuisset a brossé un tableau exhaustif des spécificités du patient coronarien diabétique. En effet, la coronaropathie du patient diabétique est une coronaropathie particulière à plus d’un titre. D’abord dans sa localisation : elle est le plus souvent diffuse, touchant les petits vaisseaux avec des lésions complexes et calcifiées, avec une évolution rapide et un risque d’instabilité de plaque importante (plaque plus sujette à rupture et donc d’événement aigu). Ensuite, dans le taux plus élevé de complications : le patient diabétique à un taux de mortalité post-syndrome coronarien aigu (SCA) plus important, un risque de saignement sous antiagrégants plus élevé, un risque d’insuffisance rénale aigüe après injection de produit de contraste plus important et enfin un taux de resténose intra-stent ou de thrombose majoré par rapport au patient non diabétique. Ce dernier risque est lié principalement à l’hyperactivité plaquettaire des patients diabétiques. Cette hyperagrégabilité plaquettaire entraîne une moindre efficacité des thérapeutiques antiplaquettaires usuelles. Par exemple, il est bien montré que l’effet de l’aspirine prise le matin s’atténue en fin de journée dans le diabète, sans effet de l’augmentation de la dose. Une prise biquotidienne permet de diminuer cet échappement (Dillinger et al. Am Heart J 2012) et un essai clinique est en cours afin de tester cette hypothèse sur le taux d’événements cardiovasculaires de patients diabétiques coronariens. Cette résistance est également observée avec le clopidogrel. En revanche, les nouveaux antiagrégants plaquettaires ticagrelor et prasugrel semblent avoir un net intérêt dans ce contexte. En effet, les études PLATO et TRITON, comparant respectivement le ticagrelor et le prasugrel versus clopidogrel en post-SCA ont montré une plus grande efficacité de ces nouvelles molécules, particulièrement chez le diabétique, sans risque augmenté d’hémorragie. Plus encore, des résultats préliminaires de l’étude THEMIS, incluant 19 000 patients diabétiques avec coronaropathie stable sans SCA, semblent indiquer que l’association ticagrelor et aspirine diminue les événements cardiovasculaires majeurs par rapport à l’aspirine seule, ce qu’avait montré l’étude PEGASUS chez des patients avec SCA de plus d’un an. Le diabétique coronarien requiert donc un traitement antiagrégant agressif et probablement plus prolongé que chez le non-diabétique.

Au-delà de l’anti-agrégation, la technique de revascularisation est importante. En effet, compte tenu de la diffusion des lésions coronaires, il est souvent de peu d’intérêt de revasculariser localement une coronaropathie chez un diabétique, le pontage aorto-coronarien semble de plus grand bénéfice. C’est ce qu’ont montré plusieurs essais conduits chez des diabétiques tritronculaires : la revascularisation chirurgicale est à chaque fois plus efficace que la revascularisation percutanée chez le diabétique, ce qui n’est pas le cas en l’absence de diabète.

En conclusion, la coronaropathie du patient diabétique présente des spécificités qu’il est nécessaire de prendre en compte dans la gestion de ces patients. Cependant, au-delà des recommandations et des données de l’evidence based medicine, le choix d’une prise en charge doit d’abord être individualisé en prenant en compte des critères cliniques qui vont au-delà du diabète. Chaque patient est unique et chaque prise en charge adaptée à son propre cas.

Louis Potier
D’après la conférence de Thomas Cuisset (Marseille)

“Publié par Diabétologie Pratique