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Richard Horton , Lancet 2005. Malattia Cronica : tempo…. “A disease that persists for a long time. A chronic disease is one lasting 3 months or more , by the definition of the U.S. National Center for Health Statistics. . “A disease lasting indefinitely. “.

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Malattia Cronica : tempo…..

“A disease that persists for a long time.

A chronic disease is one lasting 3 months or more, by the definition of the U.S.

National Center for Health Statistics.

“A disease lasting indefinitely. “

“An illness marked by long duration or frequent recurrence”

Malattia Cronica : prognosi….

“Chronic diseases generally cannot be preventedby vaccines or cured by

medication, nor do they just disappear

“A disease that can be controlled but not cured”

“A disease with one or more of the following characteristics: permanence,

leaves residual disability, caused by non-reversible pathological alternation,

requires special training of the patient for rehabilitation, or may require a

long period of supervision, observation, or care”


Cause delle malattie croniche l.jpg

Determinanti

socioeconomici

culturali ,politici,

ambientali

Fattori di rischio

intermedi

Fattori di rischio

comuni , modificabili

Dieta incongrua

Sedentarietà

Uso di tabacco

Ipertensione

Ipotolleranza

glucidica

Obesità

Dislipidemia

Globalizzazione

Urbanizzazione

Invecchiamento

della popolazione

Fattori di rischio

non modificabili

Età

Ereditarietà

Cause delle malattie croniche

MALATTIA

CRONICA

Mal CV

Diabete

BPCO

Neoplasia


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Preventing chronic diseases: a vital investment — WHO global report. Geneva:

World Health Organization, 2005.


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Preventing chronic diseases: a vital investment — WHO global report. Geneva:

World Health Organization, 2005.


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Did you know?? global report. Geneva:

Chronic diseases

  • Cardiovascular disease, mainly heart disease, stroke

  • Cancer

  • Chronic respiratory diseases

  • Diabetes

35 000 000

Strong et al, Lancet 2005


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Millions of Cases of Diabetes in 2000 and Projections for 2030, with Projected Percent Changes.

Data are from Wild S et al. : Diabetes Care 2004;27:1047


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Booth GL Lancet 2030, with Projected Percent Changes.2006; 368: 29–36

Relation between age and rates of AMI or death from any cause in men and women according to presence of diabetes and previous AMI

Recent AMI: polynomial distribution. No recent AMI: exponential istribution.R2 >0,97 for each dotted line. Recent AMI=within 3 years of baseline.

Diabetes confers an equivalent

risk to ageing 15 years


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Prevalence of Diabetes* 2030, with Projected Percent Changes.

P=0.004

* Self-reported history of diagnosed diabetes

S2 vs. S1 : P=0.21

S3 vs. S2 : P=0.02

S3 vs. S1 : P=0.001

Euro Heart Survey Programme 2007ESC Quality Assurance Programme to Improve Cardiac Care in Europe


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Risks are increasing 2030, with Projected Percent Changes.


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Prevalence of Obesity* 2030, with Projected Percent Changes.

P=0.0006

S2 vs. S1 : P=0.009

S3 vs. S2 : P=0.051

S3 vs. S1 : P=0.0002

* Body mass index ≥ 30 kg/m²

Euro Heart Survey Programme 2007ESC Quality Assurance Programme to Improve Cardiac Care in Europe


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Estimated prevalence of GOLD stage 2 or higher COPD 2030, with Projected Percent Changes.

Mannino DM :Lancet 2007; 370: 765–73


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The 2030, with Projected Percent Changes.ARIC Study:Mannino DM:Respir Med 2006; 100: 115


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Funzione 2030, with Projected Percent Changes.

Normali oscillazioni stato clinico

Riacutizzazioni ?

CHEST 2000; 117:398S

tempo

Peggioramento acuto, inatteso, sostenuto…

Respiratori

  • dispnea(respiro corto, rapido)

  • tosse

  • espettorato  purulento

Segni e sintomi

Sistemici

  • temperatura

  • frequenza cardiaca

     stato mentale

Cosa e’una riacutizzazione di BPCO dal punto di vista clinico?


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38-55%, 2030, with Projected Percent Changes. 266 - 385 milioni

27%, 130 milioni

28%, 50 milioni

prevalenza di ipertensione arteriosa nel mondo:

un’ epidemia incombente

1 miliardo di ipertesi

USA & Canada

Europa

Cina

Wolf-Maier K et al. Hypertension 2004 JNC 7 2003 Dongfeng G et al Hypertension 2002


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Pressione e mortalità 2030, with Projected Percent Changes.

ictus

Ischemia cardiaca

sistolica

diastolica


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IV=(P≥65/P≤14)*100 2030, with Projected Percent Changes.

242.0


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(da Pulignano G, 2005) 2030, with Projected Percent Changes.


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Sempre più su………. 2030, with Projected Percent Changes.


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Number of Cardiovascular Deaths Projected to 2020 2030, with Projected Percent Changes.

Millions


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Si può fare qualcosa? 2030, with Projected Percent Changes.


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160 DIABETICI TIPO 2 2030, with Projected Percent Changes.

FOLLOW UP 7.8 ANNI

ETA’ MEDIA 55 A.

TUTTI MICROALBUMINURICI

Terapia intensiva su tutti i

fattori di rischio

- 20%

Morte + eventi

cardiovascolari

Gaede P. NEJM 2003;348:383


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Benefici della terapia antipertensiva dimostrati nei trials con PA clinica(riduzione di circa 10 sist./5 dia. mmHg)

–35-40%

-20-25%

-50%

Riduzione % del rischio relativo

rallentamento progressione IR


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RR=0.64 con PA clinica


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BMJ con PA clinicapublished online 11 Oct 2007;

12 studi , 8307 pazienti


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Home Based Intervention con PA clinica

  • 297 pts per 4.2 anni

  • età media 75 anni

  • 50% ischemici

  • 30% diabetici

+ 28%

Stewart S Circulation 2002;105:2861


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Authors’ conclusions con PA clinica

Exercise training improves exercise capacity and quality of life in patients mild to moderate heart failure in the short term. One study found beneficial effects of exercise on cardiac mortality and hospital readmissions over 3 years of follow-up, the remaining included studies did not aim to measure clinical outcomes and were of short duration.

The findings of the review are based on small-scale trials in patients who are unrepresentative of the total population of patients with heart failure.

Other groups (more severe patients, the elderly,women) may also benefit. Large-scale pragmatic trials of exercise training of longer duration, recruiting a wider spectrum of patients are needed to address these issues.

The Cochrane Library 2007, Isssue 4


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BMJ 2006;332:1379 con PA clinica


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A U T H O R S ’ C O N C L U S I O N S con PA clinica

“The results of this meta-analysis strongly support respiratory rehabilitation including at least four weeks of exercise training as part of the spectrum of management for patients with COPD.

We found clinically and statistically significant improvements in important domains of quality of life, including dyspnea, fatigue emotional function.

When compared with the treatment effect of other important modalities of care…rehabilitation resulted in greater improvements in important domains of health-related quality of life and functional exercise capacity.”


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Conclusion con PA clinica

Early pulmonary rehabilitation after admission to hospital for acute exacerbations of COPD is safe and leads to statistically and clinically significant improvements in exercise capacity and health status at three months.

BMJ 2004;329:1209–11


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BMJ con PA clinica2004;329:1209–11



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Compliance con PA clinica

Adherence


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Nella cronicità il paziente deve assumere e condividere la con PA clinicaresponsabilità della terapia e della sua salute

La formazione del paziente ad un’autogestione consapevole della malattia diventa parte integrante della terapia

La terapia nella malattia cronica


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Adesione e malattie croniche con PA clinica

  • Nonostante la ricerca clinica abbia raggiunto risultati rilevanti

  • per il trattamento e per il controllo delle patologie croniche,

  • più del 50% dei pazienti cronici

  • non riesce ad eseguire correttamente la terapia consigliata


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Che fa il buon dottore? con PA clinica

  • Good doctors use

  • both

  • individual clinical expertise

  • and

  • the best available evidence,

  • and

  • neither is enough

Sackett DL et al, BMJ 1996; 312: 71-2







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The global goal con PA clinica

  • A 2% annual reduction in chronic disease death rates worldwide, per year, over the next 10 years.

  • The scientific knowledge to achieve this goal already exists.



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Combined effects of 3 interventions con PA clinicathat each reduce relative risk by 25% (20%)

Three successive 25% RR reductions

Three successive 20% RR reductions

Number of interventions


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9 out of 10 lives saved: con PA clinicalow and middle income countries


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Economic gain: billions con PA clinica


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Potential for Europe con PA clinica

  • If there are 40 million individuals with a 10 year CV risk of 25%

  • In the absence of treatment every year there will be 1 million strokes and HA

  • About half these could be averted (10 year CV risk 11.25%)



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The cardiovascular con PA clinica

toll of stress

Brotman DJ Lancet 2007;370:1089


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Estimated decrease in blood pressure mediated by con PA clinicanon-pharmacological intervention in hypertension

Messerli, Williams, Ritz. Lancet 2007; 370: 591


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Blood pressure control con PA clinica

Glycemic control

Lipid lowering

Weight loss

Potential therapeutic strategies to prevent the develoment and/or progression of cardiovascular disease

Combination treatment in a unique “polypill”?


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Combination Pharmacotherapy and Public Health Research con PA clinicaWorking Group Report (CDC & US Experts)

  • Developing countries may manufacture and distribute variations of Combination Pharmacotherapy without waiting for the developed world.

  • We think Combination Pharmacotherapy offers the potential to decrease the incidence of CVD worldwide.

  • This expert panel believes that the concept of CP shows sufficient promise to justify the additional scientific testing of its potential public health applications.

  • Specifically, we recommend further evaluation

(Ann Intern Med. 2005;143:593)


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“ Regimens of con PA clinicaaspirin, two blood-pressure drugs, and a statin could halve the risk of death from cardiovascular disease in high-risk patients.

This approach is cost-effective according to WHO recommendations, and is robust across several estimates of drug efficacy and of treatment cost.

Developing countries should encourage the use of these inexpensive drugs that are currently available for both primary and secondary prevention.”


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ISO Format con PA clinicaMENDIS, Shanthi et al. WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE). Bull World Health Organ, Nov. 2005, vol.83, no.11, p.820-829. ISSN 0042-9686.. WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)


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ISO Format con PA clinicaMENDIS, Shanthi et al. WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE). Bull World Health Organ, Nov. 2005, vol.83, no.11, p.820-829. ISSN 0042-9686.. WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)


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Letter con PA clinica

Polypill debate continues

People will always be sceptical

Letter

"Polypill" to fight cardiovascular disease

Interpretation of trial data is optimistic

Letter

"Polypill" to fight cardiovascular disease

Birthday present was much appreciated

Letter

"Polypill" to fight cardiovascular disease

Now who's playing God?

And so on…


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“ Regimens of con PA clinicaaspirin, two blood-pressure drugs, and a statin could halve the risk of death from cardiovascular disease in high-risk patients.

This approach is cost-effective according to WHO recommendations, and is robust across several estimates of drug efficacy and of treatment cost.

Developing countries should encourage the use of these inexpensive drugs that are currently available for both primary and secondary prevention.”


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RIGHT or WRONG? con PA clinica

“The dogs howl, but the moon still keeps on shining”

BMJ letter from a medical student

“Now who's playing God?”

BMJ letter from S. Taylor and A. Konings

A Polypill for Everything ?

Is polypill approach feasible and effective in preventing cardiovascular damage?


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Ingredients of Polymeal: con PA clinica

Wine(150 ml/day)

Fish (114 g 4 times/week)

Dark chocolate(100 g/day)

Fruit & vegetables(400 g/day)

Garlic(2.7 g/day)

Almonds(68 g/day)

BMJ 2004; 329: 1447


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Lifetime effect of Polymeal at age 50 con PA clinica

Total life expectancy

Life expectancy free from CVD

None

Polymeal

+8.1 yrs

+4.8 yrs

+6.6 yrs

+9.0 yrs

Years

Years

Franco OH et al. BMJ 2004; 329: 1447


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“It may be argued that the Polypill is even more effective, but the Polymeal promises to be an effective, non-pharmacological, safe, and tastyalternative for reducing cardiovascular morbidity and increasing life expectancy in the general population.”

Franco OH et al. BMJ 2004; 329: 1447


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The REACH Study ( effective, but the Polymeal promises to be an 30.000 pts, 52% donne)

Mc Cullough PA JACC 2002;39:60


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CLINIC OR HOME BASED effective, but the Polymeal promises to be an

INTERVENTIONS?


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Veramente, io ero sicuro che……. effective, but the Polymeal promises to be an


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Reality: effective, but the Polymeal promises to be an 80% of chronic disease deaths occur in low & middle income countries


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Facing illness and deepening poverty effective, but the Polymeal promises to be an


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Reality: chronic diseases affect effective, but the Polymeal promises to be an men and women almost equally


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Reality: effective, but the Polymeal promises to be an poor and children have limited choice

The next

generation


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Strong et al, Lancet 2005 effective, but the Polymeal promises to be an


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Cost benefit effective, but the Polymeal promises to be an

DENARO/DENARO

Burden of disease

IMPATTO SULLE CAUSE

DI MORTE/ SPERANZA DI VITA

Cost effectiveness

COSTO/ANNI DI VITA

GUADAGNATI

(anni senza disabilità)

DALY

OGGETTIVO

Cost utility

(anni in buona qualità di vita

percepita)

QALY

SOGGETTIVO


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Blood pressure control effective, but the Polymeal promises to be an

Glycemic control

Lipid lowering

Weight loss

Potential therapeutic strategies to prevent the develoment and/or progression of cardiovascular disease

Combination treatment in a unique “polypill”?


Slide88 l.jpg

“ Regimens of effective, but the Polymeal promises to be an aspirin, two blood-pressure drugs, and a statin could halve the risk of death from cardiovascular disease in high-risk patients.

This approach is cost-effective according to WHO recommendations, and is robust across several estimates of drug efficacy and of treatment cost.

Developing countries should encourage the use of these inexpensive drugs that are currently available for both primary and secondary prevention.”


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