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Sesión
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d of Internal Medicine
Annals
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20 de Enero de 2012
M
e José A. Herrera Rubio
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Ann Intern Med. 2011;155:820-826.
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METODOS
Búsqueda de publicaciones en inglés en PubMed desde
1985 hasta Agosto de 2011
Keywords: vitamin D, stroke, and cardiovascular
disease, solas o en combinación
Dos autores independientes analizaron el diseño,
características poblacionales y resultados.
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DEFINICION DE DEFICIT DE VITAMIN D
Guía de la IOF
Insuficiencia de vit D: 25-(OH)D < 50 nmol/L (75 nmol/L)
Deficiencia < de 25 nmol/L.
¿el nivel plasmático de 25-(OH)D refleja el estatus de la
vitamina D?
New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
PREVALENCIA MUNDIAL
Hyppönen E, Power C. Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary
and lifestyle predictors. Am J Clin Nutr. 2007;85:860-8. [PMID: 17344510]A 2007:
7437, casi la mitad tenían niveles inferiores a 40 nmol/L durante invierno y primavera
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Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly:
consequences for bone
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A [PMID: 11493580]
loss and fractures and therapeutic implications. Endocr Rev. 2001;22:477-501.
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Revisión Europea, prevalencia de deficiencia (25 nmol/L) entre un 2 y un 30%, que aumenta hasta el 75%
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Mithal A, Wahl DA, et al; IOF Committee of Scientific Advisors
(CSA) Nutrition Working Group. Global
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c D. Osteoporos Int. 2009; 20:1807-20. [PMID:
vitamin D status and determinants of hypovitaminosis
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19543765]
e brasileñas potmenopaúsicas hasta 92% en Coreanas.
Con un nivel de 75 nmol, desde el 42% en mujeres
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
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Ancianos, mujeres y niños, de áreas geográficamente predispuestas
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
Déficit de Vit D y Enfermedad Cardiovascular
Ambas se incrementan con la latitud
Variación estacional de la Cardiopatía Isquémica, menor en verano
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Se atribuye un papel a la vitamina D en el mantenimiento de la salud cardiovascular por
- Efecto sobre miocardiocitos,
- Control de la calcemia
- Acción hormonal directa en múltiples tejidos:
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- El incremento de ARP y subsecuente HTA
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- Disfunción Endotelial
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
Déficit de Vit D y Enfermedad Cardiovascular
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Conclusion:
The association between vitamin D status and cardiometabolic outcomes is uncertain.
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Trials showed no clinically significant effect of vitamin D supplementation at the dosages given.
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
Déficit de Vit D y Enfermedad Cardiovascular
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
Déficit de Vit D y Enfermedad Cardiovascular
Wang TJ, Pencina MJ, Booth SL, Jacques PF, Ingelsson E, Lanier K, et al. Vitamin D deficiency and risk of
cardiovascular disease. Circulation. 2008;117:503-11
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1700, área de Framingham, edad media de 59 años sin previa ECV.
Se medía y el nivel de 25-OH vitD y prospectivamente se veía la incidencia de ECV.
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Para niveles < 37 nmol/L, RR era de 1.62 (95% CI, 1.11 to 2.36; P 0.01) comparado con niveles superiores,
estos datos se vieron únicamente en pacientes con HTA.
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Low vitamin D levels are linked with incident cardiovascular disease and proposed several
potential mechanisms to explain their findings, including the role of 1,25-(OH)D in the renin–
angiotensin axis by direct inhibition of renin gene expression and the potential role of
vitamin D in vascular function, including inflammation, smooth muscle growth, and
thrombosis.
Because positive findings were found only in patients with hypertension, the investigators
proposed that hypertension could enhance the adverse effects of hypovitaminosis D on the
cardiovascular system because of their joint roles in vascular remodeling.”
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
Déficit de Vit D y Enfermedad Cardiovascular
Bostick RM, Kushi LH, Wu Y, Meyer KA, Sellers TA, Folsom AR. Relation of calcium, Vitamin D, and dairy
food intake to ischemic heart disease mortality among postmenopausal women. Am J Epidemiol. 1999 ;
149:151-61.
Unico estudio que incluyendo población general demuestra una reducción de enfermedad
cardiovascular con la suplementación de vitD
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Los suplementos: beneficio moderado en pacientes con
HTA y déficit de vit D
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nDt and risk of myocardial infarction in men:
Giovannucci E, Liu Y, Hollis BW, Rimm EB. 25-hydroxyvitamin
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a prospective study. Arch Intern Med. 2008;168:1174-80. a
in
18 000 hombres
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d vit D y riesgo de IAM, aún después de ajustar los FR
Significación estadística entre bajos niveles dee25OH
tradicionales.
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
VITAMIN D DEFICIENCY AND ENDOTHELIAL
DYSFUNCTION
Sugden JA, Davies JI, Witham MD, Morris AD, Struthers AD. Vitamin D improves endothelial function in patients with type 2 diabetes mellitus and low
vitamin D levels. Diabet Med. 2008;25:320-5. [PMID: 18279409]
Andrade J, Er L, Ignaszewski A, Levin A. Exploration of association of 1,25-OH2D3 with augmentation index, a composite measure of arterial stiffness.
Clin J Am Soc Nephrol. 2008;3:1800-6. [PMID: 18922995]
Dong Y, Stallmann-Jorgensen IS, Pollock NK, Harris RA, Keeton D, Huang Y, et al. A 16-week randomized clinical trial of 2000 international units
daily vitamin D3 supplementation in black youth: 25-hydroxyvitamin D, adiposity, and arterial stiffness. J Clin Endocrinol Metab. 2010;95:4584-91.
Momiyama Y, Ohmori R, Tanaka N, Kato R, Taniguchi H, Adachi T, et al. High plasma levels of matrix metalloproteinase-8 in patients with unstable
angina. Atherosclerosis. 2010;209:206-10. [PMID: 19674746]
Kai H, Ikeda H, Yasukawa H, Kai M, Seki Y, Kuwahara F, et al. Peripheral blood levels of matrix metalloproteases-2 and -9 are elevated in patients with
acute coronary syndromes. J Am Coll Cardiol. 1998;32:368-72.
61. Timms PM, Mannan N, Hitman GA, Noonan K, Mills PG, Syndercombe-Court D, et al. Circulating MMP9, vitamin D and variation in
the TIMP-1 response with VDR genotype: mechanisms for inflammatory dam-age in chronic disorders? QJM. 2002;95:787-96.
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Todos demuestran que los suplementos mejoran los marcadores de función endotelial,
frente a placebo.
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
VITAMIN D AND HYPERTENSION
El mecanismo propuesto es el papel de la vit D en la inhibición del eje R –A-A
La hipocalcemia y el hiperpara secundario
- Incremento de la rigidez arterial, por defecto vasodilatador
- Inducción de arterioesclerosi, por estímulo de la célula muscular lisa y disfunción
endotelial.
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Pfeifer M, Begerow B, Minne HW, Nachtigall D, Hansen C. Effects of a short-term vitamin D(3) and calcium
supplementation on blood pressure and parathyroid hormone levels in elderly women. J Clin Endocrinol Metab. 2001;
86:1633-7.
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Doble Ciego, Randomizado y Controlado
148 mujeres
Suplementación con Ca y Vit D frente a Ca y placebo
Se consiguió aumentar 25-(OH)D, disminuir PTH
Y además disminuir PAS y FC, comparado sólo con suplemento de Ca aislado
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New Insights About Vitamin D and Cardiovascular Disease A Narrative Review
Cora McGreevy, MB, BCh, BAO, and David Williams, MB, BAO, BCh, PhD
Ann Intern Med. 2011;155:820-826
CONCLUSION
Emerging evidence indicates that vitamin D deficiency, cardiovascular disease, and
endothelial dysfunction are linked by biological associations.
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However, no clear evidence indicates that vitamin D supplementation has a role to play
in the prevention of cardiovascular disease, outside of clinical studies.
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Despite some concerns that vitamin D may merely be a surrogate marker for poor health
status, further (preferably large) studies are needed to evaluatethe efficacy of vitamin D
supplementation.
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These trials should aim to test the hypotheses generated by multiple observational
studies and provide evidence on whether vitamin D supplementation may play a role in
cardiovascular protection.
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Ann Intern Med. 2012;156:45-51.
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CURRENT UNDERSTANDING OF ADVANCED DEMENTIA
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Curso Clínico
Estudio CASCADE, (Mitchell SL, Teno JM, et al. The clinical course of advanced dementia. N
Engl J Med. 2009;361:1529-38)
A los18 meses,
55% murió
41% neumonía,
51% episodios febriles
86% dificultades alimenticias
Pronóstico
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Mitchell SL, Miller SC, Teno JM, et al Prediction of 6-month survival of nursing home residents with
advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA. 2010;304:1929-35.
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Tool predicted 6-month survival with only modest accuracy (area under the receiver-operating characteristic curve, 0.67); however, these findings were better than those of current Medicare hospice
eligibility guidelines (area under the receiver-operating characteristic curve,0.55).
The difficulty of estimating 6-month survival in advanced dementia suggests that access to
palliative care for these patients should be guided not by their prognosis but rather by their
preference to focus care on maximizing comfort and quality of life.
Advanced Dementia: State of the Art and Priorities for the Next Decade
Susan L. Mitchell, MD, MPH; Betty et al
Ann Intern Med. 2012;156:45-51.
Causas de Distress
Dolor y Disnea
Manejo de las Compliaciones más Frecuentes
Tratamiento de los transtornos alimenticios
¿Sonda o no?
En USA 1/3 de los atendidos en residencias están con sonda
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Meier DE, Ahronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High short-term mortality in hospitalized patients with
advanced dementia: lack of benefit of tube feeding. Arch Intern Med. 2001;161:594-9
Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home
residents with severe cognitive impairment. Arch Intern Med. 1997;157:327-32.
Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA.
1999;282:1365-70
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have consistently failed to demonstrate any clinical benefits of this intervention in this
population. This evidence, together with an appreciation of eating problems as part of the
natural history of advanced dementia, has led experts to advocate against the use of tube
feeding in this condition
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Decision making for infections involves whether to administer antimicrobials or to use
supportive measures only.
Advanced Dementia: State of the Art and Priorities for the Next Decade
Susan L. Mitchell, MD, MPH; Betty et al
Ann Intern Med. 2012;156:45-51.
Utilización de Recursos Sanitarios
Los enfermos institucionalizados, en los últimos 90 días de vida ingresan una media de 1,6
veces
Van der Steen JT, Kruse RL, et al. Treatment of nursing home residents with dementia and lower respiratory tract infection in the United States and
The Netherlands: an ocean apart. J Am Geriatr Soc. 2004;52:691-9.
Givens JL, Jones RN, Shaffer ML, Kiely DK, Mitchell SL. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med.
2010;170:1102-7.
Loeb M, Carusone SC, Goeree R, Walter SD, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia:
a randomized controlled trial. JAMA.2006;295:2503-10.
Fried TR, Gillick MR, Lipsitz LA. Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with
pneumonia.J Gen Intern Med. 1995;10:246-50.
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t dementia (for
“ most conditions precipitating hospitalization in advanced
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example,pneumonia) can be treated with the sameaefficacy in the community or nursing
in is the priority hospitalization is seldom
home setting. For most patients for whom comfort
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consistent with this goal, albeit with rare exceptions
(for example, a hip fracture).”
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Los Cuidados Paliativos
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Principal factor de mal
S pronóstico a la hora de recibir cuidados: No ser Blanco
Diferencias Geográficas
Advanced Dementia: State of the Art and Priorities for the Next Decade
Susan L. Mitchell, MD, MPH; Betty et al
Ann Intern Med. 2012;156:45-51.
Propuestas para mejorar la asistencia
Mejor Acceso a los Cuidados Paliativos
Promover las Ultimas Voluntades: No Hospitalización, Sondas
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Mejorar la Información al paciente y familia
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Remitir a Residencias con Unidades de Demencia
Mejorar la asistencia domiciliaria
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