Post on 01-May-2015
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La ricerca nello scompenso cardiaco acuto: ci sono reali
novità?
Aldo P MaggioniCentro Studi ANMCO
Firenze
L’epidemiologia dello scompenso acuto rimane un
problema rilevante senza segni di miglioramento nel
tempo
AHF vs CHF outcomes
Lee DS, Lee DS, Am. J. Med. 2004Am. J. Med. 2004
La ricerca sui trattamenti dello scompenso cardiaco acuto
Fallimenti Semidelusioni Piccoli successi
Sopravvivenza dei farmaci per lo S.C. grave
Xamoterolo
1990 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 1998
Milrinone(PROMISE)
Vesnarinone(VEST)
Ibopamina(PRIME-2)
Pimobendan
FlosequinonEpoprostenol
Bosentan(First)
(REACH-1)
La ricerca sui trattamenti dello scompenso cardiaco acuto
Fallimenti Semidelusioni
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
A. Mebazaa et al., JAMA 2007, 297: 1883-1891
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
A. Mebazaa et al., JAMA 2007, 297: 1883-1891
BNP
A. Mebazaa et al., JAMA 2007, 297: 1883-1891
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007A. Mebazaa et al., JAMA 2007, 297: 1883-1891
A. Mebazaa et al., JAMA 2007, 297: 1883-1891
La ricerca sui trattamenti dello scompenso cardiaco acuto
Fallimenti Semidelusioni Piccoli successi
M.A. Konstam et al., JAMA 2007, 297: 1319-1331
M.A. Konstam et al., JAMA 2007, 297: 1319-1331
Per cominciare a ragionare più seriamente
E’ possibile fare una stratificazione dei rischi affidabile ?
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
EHS HF II: data collection
Patients screened at the emergency area, including cardiac care unit (CCU) or intensive care unit (ICU), as well as on ward facilities (internal medicine or cardiology)
133 participating hospitals: university hospitals (47%) community or district hospitals (49%) private clinics (4%)
30 European countries Recruitment from 21 October 2004 until 31 August
2005
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
EHFS II: All-Cause in-Hospital Mortality
6.6%
39.6%
5.3% 5.4%
n. 3580 pts n. 139 pts n. 2202 pts n. 1239 pts
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
Univariate analysis: in-hospital mortality by age, SBP and creatinine at hospital entry
<65 65-80 >80 >130 110-130 <110 <1.4 1.4-2.0 >2.0
3.0%
5.1%
9.3%
3.4%
5.7%
10.8%
3.4%
6.4%
12.9%
(n. 3441 patients)
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
EHFS II: All-cause in-hospital mortalityby strata of risk score
Risk score
N. of pts 772 743 726 574 305 321
1-Specificity
0,0 0,2 0,4 0,6 0,8 1,0
Se
nsi
tivity
0,0
0,2
0,4
0,6
0,8
1,0
AUC = 0.781
Per cominciare a ragionare più seriamente
E’ possibile fare una stratificazione dei rischi affidabile ?
Quali end-point e a quali tempi dobbiamo misurarli ?
Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007
Chronic HF
ACS
All-cause mortality:The lessons learned from trials and registries...
Acute HF
Opasich C et al. for the IN-CHF Investigators. Am J Cardiol 2000; 86: 353-357GISSI-3: Six-month data. J Am Coll Cardiol 1996; 27: 337-344
Tavazzi L et al. The Italian survey on Acute Heart Failure. Eur Heart J 2006; 27: 1207-1215
Research in acute HF: Conclusions
Morbidity and mortality of patients with acute HF remain unacceptably high
Treatment of acute HF continues to remain largely anecdotal without much progress in the last decades
Risk stratification with the identification of simple clinical variables seems to be feasible in any clinical setting
In any case, the application of risk scores in the real world of acute HF could be limited by: The heterogeneity of this clinical condition The different patho-physiological background The various clinical settings (and doctor profiles) in which patients with AHF
are managed Further efforts should be focused on planning research in the
field of AHF
What do we need ?
Data on the clinical characteristics. Definition, sub-clasification (ST/non-ST ) Data on the exact pathophysiology of each
subtype. Better ways to risk-stratify the patients. Treatments to:
Reduce MortalityReduce Morbidity (worsening heart failure?)Rapid and safe symptoms relief
Or in other words … everything…
Comparison of decompensated heart failure with acute myocardial infarction
Decompensated Acute myocardial Heart failure infarction
Hospitalization per year(in US) 1,000,000 1,000,000
In-Hospital Mortality 3-12% 3-7%
Readmission rate (60 days) 35% 10%
Guidelines for risk stratification No Yes
Guidelines for therapy Yes (ESC) Yes
No (AHA/ACC)
Largest randomized trial 4,133 41,021
MEDLINE citations (1965-2006) 472 33,908
Modified from Am Heart J 2003; 145: S18-25