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La gestione della Dimissione Ospedaliera e della Prevenzione Secondaria.

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Presentazione sul tema: "La gestione della Dimissione Ospedaliera e della Prevenzione Secondaria."— Transcript della presentazione:

1 La gestione della Dimissione Ospedaliera e della Prevenzione Secondaria

2 Hospital ED Admit? CCU? Transfer? CCU Acute Cath? Tx to Floor? In Lab Revasc? Other Rx? Pre- Discharge Right meds Right pt Education 3-Mo Eval Re-assess EF Lipids at goal? On right meds? On right dose? Depression? Other risks addressed? Transitional ACS Care: Not missing the steps

3 International Variation in and Factors Associated With Readmission After MI Kociol RD, et al. JAMA. 2012;307:66 Assessment of Pexelizumab in ACS study

4 Adjusted Odds Ratio of 30-Day Post-Discharge Readmission Kociol RD, et al. JAMA. 2012;307:66

5 30 day and 31–365 day mortality after first time hospitalisation for myocardial infarction between 1984 and 2008 in a Danish nationwide cohort study Schmidt et al. BMJ 2012

6 SCA: Punta dellIceberg dellAterotrombosi SCA = sindrome coronarica acuta; UA = unstable angina; NSTEMI = non ST-segment elevation myocardial infarction; STEMI = ST-segment elevation myocardial infarction. Adapted from Bhatt DL. J Invasive Cardiol. 2003;15(suppl B):3B-9B. Subclinico Persistenza ipereattività Piastrinica Presenza di Placche Coronariche multiple Infiammazione vascolare Clinico Rottura Acuta placca evento: (UA/NSTEMI/STEMI)

7 Prevenzione secondaria Scopo del Trattamento Migliorare la sopravvivenza Prevenire il Reinfarto Prevenire il rimodellamento del VSx Prevenire lo scompenso cardiaco Ridurre il rischio di aritmie

8 Statistiche US: Eventi post-SCA Eventi a 5 aa Morte (%) IM ricorrente o CHD fatale (%) Scompenso (%) aa M15167 F22 12 > 70 aa M F OConnor R et al.Circulation 2010

9 Torabi, A. et al. J Am Coll Cardiol 2010;55:79-81 Proportion of Patients Who Died With or Without Preceding Evidence of HF Subsequent to Discharge From Index Admission 7773 pts 896 pts

10 Steg GRACE Registry Circulation 2004 Di Chiara BLITZ Study Eur Hear J 2003 Killip >1 = 22% Scompenso cardiaco = 20% Nicolosi GISSI-3 trial Eur Heart J 1996 Frazione di eiezione < 40% = 16% Frazione di eiezione < 45% = 25% IN-ACS Outcome on file Incidenza di scompenso e disfunzione ventricolare sinistra postinfartuale Dati SDO pazienti dimessi dopo infarto miocardico acuto con indicazione a riabilitazione cardiologica degenziale

11 G Ital Cardiol 2011;12 (3):

12 Documento di consenso ANMCO-IACPR/GICR Criteri di accesso alla riabilitazione cardiologica degenziale Premesse fondamentali G Ital Cardiol 2011;12 (3): Modificazioni dellepidemiologia clinica dell IMA - Concetto di prioritàalla riabilitazione cardiologica - Priorità allalto rischio clinico - Riformulazione dellofferta delle strutture riabilitative

13 1.Scompenso cardiaco e/o FE 1/ Accesso a Cardiologia riabilitativa degenziale o, in sua assenza, controlli precoci < 30 gg 2. Predittori di rimodellamento e scompenso (FE, riempimento diastolico restrittivo, WMSI, livello enzimi, età, IM =1) 3. Predittori di re-infarto miocardico (diabete mellito, caratteristiche malattia coronarica, insufficienza renale, risultato subottimale procedure, persistenza rischio cardiovascolare elevato) 4. Livello di fattori di rischio cardiovascolare Controllo clinico strumentale a 30 giorni Gerarchia delle variabili prognostiche utili alla dimissione, percorso assistenziale e timing dei controlli CEN ANMCO-GIC 2011

14 Criteri per la selezione dei pazienti da inviare nei Centri di Cardiologia Riabilitativa Documento di Consenso ANMCO /GICR-IACPR … Il Panel ritiene quindi prioritario linvio a strutture riabilitative degenziali, dopo la fase acuta, dei pazienti IMA ad alto rischio clinico: IMA con scompenso o con disfunzione ventricolare sinistra (frazione di eiezione inferiore al 40%). IMA con ricoveri prolungati in fase acuta o con complicanze o con comorbidità IMA in persone che svolgono vita estremamente sedentaria o anziani Il Panel ritiene prioritario un ciclo riabilitativo preferibilmente ambulatoriale per pazienti con alto rischio clinico- cardiovascolare: Rivascolarizzazione incompleta, coronaropatia diffusa o critica, multipli fattori di rischio, resistenza a mutare lo stile di vita, specie se in pazienti giovani

15 Hospital discharge summary: –Confirms diagnosis –Provides results of investigations performed and future investigations required –Documents any in-hospital complications and resulting interventions –Provides details of medication prescribed with guidance on up-titration –Includes the patients agreed care plan All patients should receive an individualised management plan, which: –Is culturally sensitive –Contains evidence-based information –Includes input from the patient and carers/family –Provides recommendations on daily living –Documents what to expect of primary care services Discharge Form

16 Discharge Protocols Enhance communication with patient and between specialist(s) and primary care physicians Shared targets for improvementShared targets for improvement High-quality data feedbackHigh-quality data feedback Medications: aspirin, thienopyridine, ACE inhibitor, β-blocker, statin Diet, exercise, smoking cessation recommendations Patient symptom awareness, Act in Time protocol Wallet-/purse-sized copy of ECG Follow-up appointments

17 Based on the guidance, the Follow Your Heart group developed complementary practical, user-friendly tools for primary care clinicians and patients Tools summarise the guidance for incorporation into day-to-day practice for clinicians and day-to-day life for patients and their families Complemetary tools for HCPs and patients

18 1.Cardiac rehabilitation and ongoing care 2.Lifestyle modification 3.Goal of intervention 4.Therapeutic interventions 5.Integrated communication Five steps to optimal post-ACS care

19 1. Cardiac rehabilitation and ongoing care Cardiac rehabilitation: –Vital to help post-MI patients improve risk factors for cardiovascular disease (CVD) –Provides link in post-MI care between primary and secondary care Each post-MI patient should have an individualised plan developed prior to hospital discharge Each cardiac rehabilitation plan should: –Enable patients to understand and take responsibility for their recovery and continued health –Introduce concept of risk and importance of cardiovascular (CV) risk factors –Address specific areas concerning patients and their partners

20 2. Lifestyle modification Lifestyle changes are essential to improve CV health Partners and family members should be encouraged to adopt positive healthy lifestyle changes together

21 Eat a healthy balanced diet 4 Consider a Mediterranean-style diet. Increase fresh food intake and reduce processed foods 5 Eat less fat. Reduce intake of foods high in saturated fat, e.g. fatty and processed meat, full-fat dairy products, biscuits, cakes, pastries and some convenience snack foods. Opt for unsaturated fats, e.g. sunflower and olive oil (polyunsaturated and monounsaturated fat) 6 Eat more fruit and vegetables – at least five portions of different types a day 7 Choose wholegrain and high-fibre foods, e.g. wholegrain rice/pasta, wholemeal bread, oats, seeds, nuts, pulses, etc 8. Eat oily fish, at least two portions a week to provide omega-3 (e.g. salmon, trout, mackerel) 9. Consider 1 g Omacor per day as an alternative Reduce salt intake, aim for <6 g a day 10. Beware of hidden salt content Consider foods enriched with plant sterols or stanols, e.g. yoghurt, milk, margarine spreads 11

22 Increase physical activity 12 Be physically active, e.g. take the stairs, walk to shops, wash the car Aim for at least 20–30 minutes of moderate activity each day to the point of mild breathlessness, e.g. walking, jogging, cycling, dancing or swimming Do not smoke 13 Post-MI patients should not smoke Smokers should be offered medication for smoking cessation and referred to local stop-smoking services Manage weight 13 Balance energy intake with energy expenditure Advice should be provided to individuals when body mass index (BMI) >25 kg/m 2 or those with an increased waist circumference If overweight aim to lose around 0.5 kg/1 lb per week Limit alcohol intake 12 Drink alcohol in moderation:, women 1–2 units/day, men 2–3 units/day

23 3. Goal of intervention Blood pressure <130/80 mmHg 13 <125/75 mmHg for patients with chronic kidney disease (CKD) 14 Goal of intervention is to achieve optimal control of all modifiable CV risk factors Clinical evidence consolidated for concise, definitive guidance on optimal targets Blood sugar HbA1c <6.5% 13 Weight BMI 13 <25 kg/m 2 Waist circumference 16 Europids o Male <94 cm o Female <80 cm South Asians and Chinese o Male <90 cm o Female <80 cm Key: BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol

24 Perk J, et al. Eur Heart J doi: /eurheartj/ehs092 European Guidelines on Cardiovascular Disease Prevention (Version 2012)

25 4. Therapeutic interventions Riduzione del rischio Aspirina – tienopiridine* 20-30% Beta-bloccanti* 20-35% ACE-inibitori* 22-25% Statine* 25-42% *I quattro farmaci con i quali devono essere trattati tutti i pazienti con aterosclerosi, salvo controindicazioni esistenti e documentate

26 Adherence Rates After Discharge for ACS if Therapy is Started In-Hospital GRACE Registry: 21,408 patients, multinational, assessment at discharge and 6 months Eagle KA, et al. Am J Med. 2004;117: ASA -blocker ACEIStatin Percent of Patients [11,465/12,463][1906/2379][6796/7738][5522/6320]

27 Discharge Medication Use *LVEF <40%, CHF, DM, HTN. Known hyperlipidemia, TC, LDL. Q CRUSADE data. © 2003 Duke Clinical Research Institute. Used with permission. Available at: 93% 89% 0% 20% 40% 60% 80% 100% Aspirinβ-BlockersACE Inhibitors* 67% Lipid- Lowering Agent 84% 67% Clopidogrel

28 Interruzione dei trattamenti raccomandati durante il follow-up in pazienti con Pregresso IMA Dati del registro SIMG - Health Search - JCVM 2009

29 Adherence to statins after two years, by condition Jackevicius CA, et al. JAMA 2002;288:462

30 Why adherence matters Results of failure to adhere to prescribed medications: Increased hospitalization Poor health outcomes Increased costs Decreased quality of life Patient death Benner JS, et al. JAMA 2002;288:455 Of all medication-related hospital admissions in the United States, 33 to 69 percent are due to poor medication adherence, with a resultant cost of approximately $100 billion a year.

31 Perk J, et al. Eur Heart J doi: /eurheartj/ehs092 European Guidelines on Cardiovascular Disease Prevention (Version 2012)

32 OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI LOsservatorio ARNO è composto da una rete di 32 ASL sparse sul territorio nazionale e raccoglie i dati di circa 10,5 milioni di abitanti. Data Dimissione 01/01/2007 Periodo di Accrual 01/01/200831/12/200831/12/2009 Pregresso (-365 gg rispetto alla data di dimissione per SCA) Follow-up (+365 gg rispetto alla data di dimissione per SCA) Pazienti con Sindrome Coronarica Acuta (nel periodo di accrual): 7.082

33 Terapia I semestreTotale% Aspirina ,4% Aspirina + Clopidogrel ,9% Aspirina + Ticlopidina 2464,7% Altra terapia antiaggregante* 4568,6% Nessuna terapia nel I semestre 751,4% Totale ,0% OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI N. pazienti: Evento indice Doppia antiaggregazione Aspirina Aspirina + Clopidogrel Aspirina + Ticlopidina solo SCA (N=4.250) (25,9%)124 (2,9%) (36,0%) SCA + Rivascolarizzazio ni (N=2.342) (70,1%)122 (5,2%)236 (10,1%)

34 Trattati con antiaggreganti nel follow-up: N. trattati aderenti nel I semestre: (68,0%) N. trattati aderenti nel I e nel II semestre: (60,3%) OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI

35 Biondi-Zoccai G, et al. Eur Heart J :2667 Aspirin Discontinuation in 50,279 CAD Patients Increased Thrombotic Risks

36 OR=89.8 ( ) HR=19.2 ( ) OR=4.8 ( ) HR=13.7 ( ) Odds/Hazard Ratio Iakovou et al. JAMA 2005 Park et al. Am J Card 2006 Kuchulakanti et al. Circulation 2006 Airoldi et al. Circulation 2007 Premature Discontinuation of Antiplatelet Tx as Predictor of Stent Thrombosis

37 Wenaweser P et al, J Am Coll Cardiol 2008;52:1134 Status of Antiplatelet Treatment and Time of Definite DES Thrombosis Early Stent Thrombosis Late Stent Thrombosis Very Late Stent Thrombosis 0% 25% 50% 75% 100% No Antiplatelet Therapy Single Antiplatelet Therapy Dual Antiplatelet Therapy 4-Year results from a large 2-Institutional (Rotterdam/Bern) cohort study 8146 patients (SES/PES implantation in )

38 Predictors of Low Clopidogrel Adherence Following PCI Adherence to daily medications before PCI assessed in 284 pts using the 8-item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (score <6), medium (score 6 to <8), or high (score 8). Muntner P, et al. Am J Cardiol 2011;108:822

39 Rossini R et al. Am J Card 2011, 107: 186 Discontinuation Causes: Surgery 34.5% Bleeding 21% Medical decision 17.6% Dental interventions 7.6% Economic/burocratic reasons 5.9% Anticoagulant therapy 5.0% 8.8% of patients discontinued one or both antiplatelet agents within the first 12 months (early discontinuation) and 4.8% withdrew aspirin after 1 year (late discontinuation) Discontinuation Causes

40 5. Integrated communication Good communication between secondary and primary care, community services and the patient is essential 12 Post-ACS hospital discharge summary is vital component of successful communication 24

41 GUIDELINES Smooth Transition From Acute Care to Long-Term Management Primary Care Secondary Prevention Cardiology Acute Care

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