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La ricerca nello scompenso cardiaco acuto: ci sono reali novità?. Aldo P Maggioni Centro Studi ANMCO Firenze. L’epidemiologia dello scompenso acuto rimane un problema rilevante senza segni di miglioramento nel tempo. AHF vs CHF outcomes. Lee DS, Am. J. Med. 2004.

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slide1

La ricerca nello scompenso cardiaco acuto: ci sono reali novità?

Aldo P Maggioni

Centro Studi ANMCO

Firenze

slide2

L’epidemiologia dello scompenso acuto rimane un problema rilevante senza segni di miglioramento nel tempo

ahf vs chf outcomes
AHF vs CHF outcomes

Lee DS, Am. J. Med. 2004

la ricerca sui trattamenti dello scompenso cardiaco acuto
La ricerca sui trattamenti dello scompenso cardiaco acuto
  • Fallimenti
  • Semidelusioni
  • Piccoli successi
slide9

1990

‘91

‘92

‘93

‘94

‘95

‘96

‘97

1998

Flosequinon

Sopravvivenza dei farmaci per lo S.C. grave

Xamoterolo

Milrinone

(PROMISE)

Vesnarinone

(VEST)

Ibopamina

(PRIME-2)

Pimobendan

Epoprostenol

(First)

Bosentan

(REACH-1)

slide14

BNP

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

slide15

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

la ricerca sui trattamenti dello scompenso cardiaco acuto16
La ricerca sui trattamenti dello scompenso cardiaco acuto
  • Fallimenti
  • Semidelusioni
  • Piccolisuccessi
slide20

Per cominciare a ragionare più seriamente

    • E’ possibile fare una stratificazione dei rischi affidabile ?
ehs hf ii data collection
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
ehfs ii all cause in hospital mortality
EHFS II: All-Cause in-Hospital Mortality

39.6%

6.6%

5.3%

5.4%

n. 3580 pts

n. 139 pts

n. 2202 pts

n. 1239 pts

univariate analysis in hospital mortality by age sbp and creatinine at hospital entry
Univariate analysis: in-hospital mortality by age, SBP and creatinine at hospital entry

12.9%

(n. 3441 patients)

10.8%

9.3%

6.4%

5.7%

5.1%

3.4%

3.4%

3.0%

<65

65-80

>80

>130

110-130

<110

<1.4

1.4-2.0

>2.0

slide26

EHFS II: All-cause in-hospitalmortality

bystrataofrisk score

Risk score

743

772

726

574

305

321

N. ofpts

slide27

Per cominciare a ragionarepiùseriamente

    • E’ possibile fare unastratificazionedeirischiaffidabile ?
    • Quali end-point e a quali tempi dobbiamomisurarli ?
slide28

All-causemortality:

The lessonslearnedfromtrials and registries...

Chronic HF

ACS

Acute HF

Opasich C et al. for the IN-CHF Investigators. Am J Cardiol 2000; 86: 353-357

GISSI-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
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 Mortality

Reduce Morbidity (worsening heart failure?)

Rapid and safe symptoms relief

Or in other words … everything…

What do we need ?
slide31

Comparisonofdecompensatedheartfailurewith acute myocardialinfarction

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

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