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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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Richard Horton , Lancet 2005

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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. “

“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”


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


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

World Health Organization, 2005.


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

World Health Organization, 2005.


Did you know??

Chronic diseases

  • Cardiovascular disease, mainly heart disease, stroke

  • Cancer

  • Chronic respiratory diseases

  • Diabetes

35 000 000

Strong et al, Lancet 2005


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


Booth GL Lancet 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


Prevalence of Diabetes*

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


Risks are increasing


Prevalence of Obesity*

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


Estimated prevalence of GOLD stage 2 or higher COPD

Mannino DM :Lancet 2007; 370: 765–73


TheARIC Study:Mannino DM:Respir Med 2006; 100: 115


Funzione

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?


38-55%,  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


Pressione e mortalità

ictus

Ischemia cardiaca

sistolica

diastolica


IV=(P≥65/P≤14)*100

242.0


(da Pulignano G, 2005)


Sempre più su……….


Number of Cardiovascular Deaths Projected to 2020

Millions


Si può fare qualcosa?


160 DIABETICI TIPO 2

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


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


RR=0.64


BMJ published online 11 Oct 2007;

12 studi , 8307 pazienti


Home Based Intervention

  • 297 pts per 4.2 anni

  • età media 75 anni

  • 50% ischemici

  • 30% diabetici

+ 28%

Stewart S Circulation 2002;105:2861


Authors’ conclusions

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


BMJ 2006;332:1379


A U T H O R S ’ C O N C L U S I O N S

“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.”


Conclusion

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


BMJ 2004;329:1209–11


“ Ma è davvero così semplice?”


Compliance

Adherence


Nella cronicità il paziente deve assumere e condividere la responsabilità 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


Adesione e malattie croniche

  • 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


Che fa il buon dottore?

  • 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


E’ necessario l’intervento del paziente


Dying slowly, painfully and prematurely


Causes of chronic diseases


The economic impact: billions


Si può fare qualcosa su base mondiale?


The global goal

  • 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.


Epping-Jordan et al, Lancet 2005


Combined effects of 3 interventions that each reduce relative risk by 25% (20%)

Three successive 25% RR reductions

Three successive 20% RR reductions

Number of interventions


9 out of 10 lives saved: low and middle income countries


Economic gain: billions


Potential for Europe

  • 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%)


The cardiovascular toll of stress


The cardiovascular

toll of stress

Brotman DJ Lancet 2007;370:1089


Estimated decrease in blood pressure mediated bynon-pharmacological intervention in hypertension

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


Blood pressure control

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”?


Combination Pharmacotherapy and Public Health Research Working 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)


“ Regimens of 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.”


ISO FormatMENDIS, 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)


ISO FormatMENDIS, 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)


Letter

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…


“ Regimens of 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.”


RIGHT or WRONG?

“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?


Ingredients of Polymeal:

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


Lifetime effect of Polymeal at age 50

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


“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


The REACH Study (30.000 pts, 52% donne)

Mc Cullough PA JACC 2002;39:60


CLINIC OR HOME BASED

INTERVENTIONS?


Veramente, io ero sicuro che…….


Reality: 80% of chronic disease deaths occur in low & middle income countries


Facing illness and deepening poverty


Reality: chronic diseases affect men and women almost equally


Reality: poor and children have limited choice

The next

generation


Strong et al, Lancet 2005


Cost benefit

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


Blood pressure control

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”?


“ Regimens of 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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