Metabolismo energético postprandial y su relación con el síndrome metabólico en pacientes con enfermedad coronaria

Resumen

1. Introducción o motivación de la tesis Aunque el establecimiento de terapias ajustadas a las recientes guías de práctica clínica para el tratamiento de la enfermedad coronaria han disminuido la incidencia de la enfermedad y han mejorado su pronóstico, esta entidad se mantiene como una de las principales causas de mortalidad en los países desarrollados, Por otra parte, esta condición representa también la primera causa de discapacidad en la edad joven y causa un alto impacto en términos de uso de los servicios de salud. La arteriosclerosis, mecanismo patológico subyacente de la enfermedad coronaria, se encuentra ligada a la presencia de varios factores de riesgo cardiovascular, destacando entre ellos como factores clásicos de riesgo la hipertensión, la dislipemia, la diabetes mellitus, el tabaquismo y la inactividad física. De los descritos, los tres primeros se relacionan estrechamente con el tipo de dieta, y su aparición está asociada con la presencia de exceso de peso u obesidad. El llamado síndrome metabólico describe una agrupación de riesgo para la enfermedad cardiovascular y la diabetes mellitus tipo 2 (DM2), incluyendo dislipidemia, intolerancia a la glucosa, hipertensión y obesidad central. Esta entidad está aumentando su prevalencia a proporciones epidémicas en todo el mundo y los mecanismos subyacentes exactos que conducen a esta no son plenamente conocidos. Así mismo, el aumento del índice de masa corporal también se ha asociado con un exceso de riesgo de mortalidad. Sin embargo, evidencias recientes sugieren que no todos los sujetos obesos muestran un agrupamiento de factores de riesgo metabólicos y cardiovasculares y, de igual modo, no todos los sujetos delgados presentan un perfil metabólico libre de enfermedad. Por este motivo, se ha prestado más atención a los diferentes fenotipos metabólicos de la obesidad, sugiriendo que los individuos en la misma categoría de índice de masa corporal pueden presentar una gran heterogeneidad en su control metabólico. Estos efectos metabólicos se hacen más fácilmente evidentes en las situaciones en las que hay un mayor estrés de las vías metabólicas, como es el caso del estado postprandial. Este hecho puede apoyar la idea de que la obesidad es una enfermedad multisistémica en la que puede acontecer una pérdida de flexibilidad en uno o más procesos metabólicos implicados. El estudio de los factores de riesgo no clásicos que influyen en las enfermedades cardíacas, como es el caso de la lipemia postprandial, está recibiendo una gran atención debido a la creciente evidencia que muestra que estos factores son determinantes claros de la incidencia y evolución de la enfermedad. No obstante, existen aún grandes interrogantes en cuestiones relacionadas con los determinantes del metabolismo postprandial. De esta forma, la motivación de nuestra investigación ha sido abordar algunos de estos interrogantes y poder determinar si los riesgos del síndrome metabólico influyen en la lipemia postprandial de los pacientes coronarios, valorar el efecto de la edad sobre ellos y si esta influencia depende del número de criterios presentes. Así mismo, se ha evaluado el concepto de fenotipos de obesidad y su impacto sobre el metabolismo postprandial. En función de lo expuesto previamente, se definen los siguientes objetivos a cumplir: Objetivo principal: - Determinar si los rasgos de síndrome metabólico influyen en la lipemia postprandial de los pacientes coronarios y si esta influencia depende del número de criterios presentes. Objetivos secundarios: - Investigar si el número de criterios del síndrome metabólico puede predecir el grado de respuesta postprandial en pacientes con TG en ayunas normales. - Determinar la contribución exacta de la presencia de síndrome metabólico sobre la lipemia postprandial aumentada asociada a la edad. - Explorar mediante un test de sobrecarga oral grasa el grado de flexibilidad fenotípica de los pacientes de alto riesgo coronario clasificados según su índice de masa corporal y la presencia o ausencia de alteración cardiometabólica. 2. Contenido de la investigación El trabajo desarrollado se ha encuadrado principalmente dentro del estudio CORDIOPREV y se exponen en función de los resultados de tres publicaciones referenciadas en Journal Citation report (JCR). El estudio CORDIOPREV es un estudio prospectivo, abierto, randomizado y controlado que incluye a 1002 pacientes con enfermedad coronaria, asignados a uno de los dos modelos de dieta (dieta mediterránea y baja en grasa) durante un período de siete años de seguimiento. Los pacientes incluidos en este estudio fueron reclutados desde Noviembre de 2009 hasta Febrero de 2012, principalmente en el Hospital Universitario Reina Sofía de Córdoba, además de otros centro hospitalarios de las provincias de Córdoba y Jaén. Como criterios de inclusión, los pacientes fueron elegibles si presentaban una edad mayor de 20 años (aunque menores de 75 años), con diagnóstico de enfermedad coronaria sin eventos clínicos en los últimos seis meses, no presentaban enfermedades graves y se estimaba una esperanza de vida superior a cinco años. Antes de que los participantes fueran asignados a los diferentes modelos dietéticos del estudio CORDIOPREV, y con un periodo de ayuno previo de 12 horas, completaron un test de sobrecarga oral grasa con una comida rica en ácidos grasos monoinsaturados con 0.7 g de grasa por Kg de peso (12%SFA, 10%PUFA, 43%MUFA), y 10% de proteínas y 25% de hidratos de carbono. Se obtuvieron muestras venosas en los tiempos 0, 1, 2, 3 y 4 horas y los pacientes fueron clasificados en función de la presencia o no de síndrome metabólico, el número de criterios presentes. Así mismo, también fueron clasificados en función de diferentes fenotipos de obesidad, definidos en función del índice de masa corporal y la presencia o no de alteraciones cardiometabólicas. La extensión y magnitud del metabolismo postprandial fue analizada en función de estos grupos. 3. Conclusión - En los pacientes con enfermedad coronaria, la lipemia postprandial se relacionó directamente con la presencia de síndrome metabólico. 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