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Richard Horton, Lancet 2005. An illness marked by long duration or frequent recurrence A disease lasting indefinitely. long time. A disease that persists.

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Presentazione sul tema: "Richard Horton, Lancet 2005. An illness marked by long duration or frequent recurrence A disease lasting indefinitely. long time. A disease that persists."— Transcript della presentazione:

1 Richard Horton, Lancet 2005

2 An illness marked by long duration or frequent recurrence A disease lasting indefinitely. long time. 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. Malattia Cronica : tempo….. 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 Malattia Cronica : prognosi…. Chronic diseases generally cannot be prevented by vaccines or cured by medication, nor do they just disappear

3 Cause delle malattie croniche Determinanti socioeconomici culturali,politici, ambientali Globalizzazione Urbanizzazione Invecchiamento della popolazione Fattori di rischio comuni, modificabili Dieta incongrua Sedentarietà Uso di tabacco Fattori di rischio non modificabili Età Ereditarietà Fattori di rischio intermedi Ipertensione Ipotolleranza glucidica Obesità Dislipidemia MALATTIACRONICA Mal CV DiabeteBPCONeoplasia

4 Preventing chronic diseases: a vital investment WHO global report. Geneva: World Health Organization, 2005.

5 Preventing chronic diseases: a vital investment WHO global report. Geneva: World Health Organization, 2005.

6 Strong et al, Lancet 2005 Cardiovascular disease, mainly heart disease, stroke Cancer Chronic respiratory diseases Diabetes Did you know?? Chronic diseases

7 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

8 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. Booth GL Lancet 2006; 368: 29–36 Diabetes confers an equivalent risk to ageing 15 years

9 Prevalence of Diabetes* P=0.004 S2 vs. S1 : P=0.21 S3 vs. S2 : P=0.02 S3 vs. S1 : P=0.001 * Self-reported history of diagnosed diabetes Euro Heart Survey Programme 2007 ESC Quality Assurance Programme to Improve Cardiac Care in Europe

10 Risks are increasing

11 Prevalence of Obesity* P= S2 vs. S1 : P=0.009 S3 vs. S2 : P=0.051 S3 vs. S1 : P= * Body mass index 30 kg/m² Euro Heart Survey Programme 2007 ESC Quality Assurance Programme to Improve Cardiac Care in Europe

12 Prevalence of Central Obesity* * Waist circumference 102 cm in men or 88 cm in women P< S2 vs. S1 : P= S3 vs. S2 : P=0.47 S3 vs. S1 : P< Euro Heart Survey Programme 2007 ESC Quality Assurance Programme to Improve Cardiac Care in Europe

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14 Estimated prevalence of GOLD stage 2 or higher COPD Mannino DM : Lancet 2007; 370: 765–73

15 The ARIC Study:Mannino DM:Respir Med 2006; 100: 115

16 Classificazione spirometrica di gravità della BPCO (GOLD 2005) STADIOCARATTERISTICHE 0: A RISCHIO Spirometria normale, sintomi cronici I: LIEVE VEMS/CVF < 70%; VEMS 80% del teorico con o senza sintomi cronici II: MODERATA VEMS/CVF < 70%; 50% VEMS < 80% del teorico con o senza sintomi cronici III: GRAVE VEMS/CVF < 70%; 30% VEMS< 50% pred. con o senza sintomi IV: MOLTO GRAVE VEMS/CVF < 70%; VEMS < 30% pred. o VEMS<50%pred. con insufficienza respiratoria cronica

17 Cosa euna riacutizzazione di BPCO dal punto di vista clinico? Segni e sintomi Peggioramento acuto, inatteso, sostenuto… temperatura frequenza cardiaca stato mentale Sistemici dispnea dispnea (respiro corto, rapido) tosse espettorato purulento Respiratori Funzione tempo Normali oscillazioni stato clinico Riacutizzazioni ? CHEST 2000; 117:398S

18 USA & Canada Europa 28%, 50 milioni 38-55%, milioni Cina 27%, 130 milioni Wolf-Maier K et al. Hypertension 2004 JNC Dongfeng G et al Hypertension 2002 prevalenza di ipertensione arteriosa nel mondo: un epidemia incombente 1 miliardo di ipertesi

19 diastolica sistolica Pressione e mortalità Ischemia cardiaca ictus

20

21 N. Ricoveri ScompensoCardiaco

22 Epidemiologia in EUROPA: prevalenza Prevalenza ICC sintomatica: 0,4-2% Aumenta con letà (età media 74 aa) È IN AUMENTO Anche la mortalità (età agg.) è in aumento 900 Milioni di europei 10 Milioni ICC Altrettanti con ICC asintomatica

23 The REACH Study ( pts, 52% donne) Mc Cullough PA JACC 2002;39:60

24 IV=(P65/P14)*

25 (da Pulignano G, 2005)

26 Sempre più su……….

27 MDGs: chronic diseases are not on the agenda Fuster V : Lancet 2005;366: Projected deaths by major cause and World Bank income group, all ages, 2005

28 Number of Cardiovascular Deaths Projected to 2020 Millions

29 Si può fare qualcosa?

30 160 DIABETICI TIPO 2 FOLLOW UP 7.8 ANNI ETA MEDIA 55 A. TUTTI MICROALBUMINURICI Terapia intensiva su tutti i fattori di rischio fattori di rischio - 20% Gaede P. NEJM 2003;348:383 Morte + eventi cardiovascolari

31 Benefici della terapia antipertensiva dimostrati nei trials con PA clinica (riduzione di circa 10 sist./5 dia. mmHg) –35-40% % -50% rallentamento progressione IR Riduzione % del rischio relativo

32 RR=0.64

33 BMJ published online 11 Oct 2007; 12 studi, 8307 pazienti

34 Stewart S Circulation 2002;105: pts per 4.2 anni età media 75 anni 50% ischemici 30% diabetici + 28% Home Based Intervention

35 Stewart S et al.: Lancet 354,1077, pts con CHF,classi NYHA II-IV,età media 75 a., comorbidità (BPCO 33%, diabete 34%) INTERVENTO : unica visita di infermiera 7-14 g da dimissio- ne(comprehensive home assessment) contatti telefonici, rapporti col curante DURATA : 6 mesi intervento + 6 mesi follow up RISULTATI: InterventoControllo End points primari 77 (-40%) 129 (ricoveri +decessi) Ricoveri urgenti68 (118) 118 (156) Giorni di ricovero Costi totali$ $ Costo/paziente$ 900 $ Costo dellintervento : $ 350/paziente Il beneficio si prolungò altri 6 mesi oltre lintervento.

36 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

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38 BMJ 2006;332:1379

39 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. A U T H O R S C O N C L U S I O N S

40 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

41 Pulmonary rehabilitation two classes per week for eight weeks. A multidisciplinary team ran the pulmonary rehabilitation programme, which consisted of two classes per week for eight weeks. Each class lasted two hours, consisting of one hour of exercise (aerobic walking and cycling, strength training for the upper and lower limb) and one hour of educational activities (with an emphasis on self management of the disease, nutrition, and lifestyle issues). Respiratory physiotherapists and nurses supervised the exercise component, as did health centre based fitness instructors. Physiotherapists, respiratory nurses, an occupational therapist, a dietician, a respiratory doctor, a smoking cessation adviser, a social worker, a pharmacist, and a lay member of a patients group supervised education activities on a rolling rota. Patients also received individualised home exercise programmes, which encouraged at least 20 minutes of exercise per day.

42 BMJ 2004;329:1209–11

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44 Ma è davvero così semplice? Ma è davvero così semplice?

45 Compliance Accettazione, osservanza delle prescrizioni mediche da parte del paziente il quale ha solo il dovere di seguire quanto prescritto significa:

46 Adherence LOMS ha promosso il termine Adherence per utilizzarlo nelle patologie croniche come il grado di comportamento di una persona che assume farmaci, che segue una dieta e/o stile di vita e risponde alle esigenze delle raccomandazioni condivise da parte delle agenzie di salute (Report on Medication Adherence Geneva –World Health Org. 2003)

47 AdherenceCompliance

48 La terapia nella malattia cronica Nella cronicità il paziente deve assumere e condividere la della terapia e della sua salute Nella cronicità il paziente deve assumere e condividere la responsabilità della terapia e della sua salute La formazione del paziente ad un consapevole della malattia diventa parte integrante della terapia La formazione del paziente ad un autogestione consapevole della malattia diventa parte integrante della terapia

49 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 Adesione e malattie croniche

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53 Che fa il buon dottore? Good doctors use both both individual clinical expertise and the best available evidence, and neither is enough Sackett DL et al, BMJ 1996; 312: 71-2

54 E necessario lintervento del paziente

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56 Dying slowly, painfully and prematurely

57 Causes of chronic diseases

58 The economic impact: billions

59 Si può fare qualcosa su base mondiale?

60 Horton, The Lancet 2005

61 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.

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63 Epping-Jordan et al, Lancet 2005

64 Number of interventions Three successive 25% RR reductions Three successive 20% RR reductions Combined effects of 3 interventions that each reduce relative risk by 25% (20%)

65 9 out of 10 lives saved: low and middle income countries

66 Economic gain: billions

67 Potential for Europe If there are 40 million individuals with a 10 year CV risk of 25% 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 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%) About half these could be averted (10 year CV risk 11.25%)

68 The cardiovascular toll of stress

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70 The cardiovascular toll of stress toll of stress Brotman DJ Lancet 2007;370:1089

71 Estimated decrease in blood pressure mediated by non-pharmacological intervention in hypertension Messerli, Williams, Ritz. Lancet 2007; 370: 591

72 Potential therapeutic strategies to prevent the develoment and/or progression of cardiovascular disease Blood pressure control Glycemic control Lipid lowering Weight loss Combination treatment in a unique polypill?

73 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 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)

74 Fixed Drug Combination for Patients with CHD Low dose antiplatelet (aspirin 75 mg) Low dose antiplatelet (aspirin 75 mg) Full dose of a statin (simvastatin 40 mg) Full dose of a statin (simvastatin 40 mg) Full dose of an ACEI (lisinopril 10 mg) Full dose of an ACEI (lisinopril 10 mg) Half dose of a BB (atenolol 25 mg) Half dose of a BB (atenolol 25 mg) The Polypill?

75 Low dose antiplatelet (aspirin 75 mg) Full dose of a statin (simvastatin 40 mg) Full dose of an ACEI (lisinopril 10 mg) Half dose of a diuretic (HCT 12.5 mg) The Polypill? Fixed Drug Combination for Patients with CVD

76 Regimens of aspirin, two blood-pressure drugs, and a statin could halve the risk of death from cardiovascular disease in high-risk patients. 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. 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. Developing countries should encourage the use of these inexpensive drugs that are currently available for both primary and secondary prevention.

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78 Fixed Drug Combination for Patients with CHD Low dose antiplatelet (aspirin 75 mg) Low dose antiplatelet (aspirin 75 mg) Full dose of a statin (simvastatin 40 mg) Full dose of a statin (simvastatin 40 mg) Full dose of an ACEI (lisinopril 10 mg) Full dose of an ACEI (lisinopril 10 mg) Half dose of a BB (atenolol 25 mg) Half dose of a BB (atenolol 25 mg) The Polypill?

79 Low dose antiplatelet (aspirin 75 mg) Low dose antiplatelet (aspirin 75 mg) Full dose of a statin (simvastatin 40 mg) Full dose of a statin (simvastatin 40 mg) Full dose of an ACEI (lisinopril 10 mg) Full dose of an ACEI (lisinopril 10 mg) Half dose of a diuretic (HCT 12.5 mg) Half dose of a diuretic (HCT 12.5 mg) The Polypill? Fixed Drug Combination for Patients with CVD

80 A pill to prevent 80% of heart attacks Paper N J Wald and M R Law BMJ 2003;326:1419 (28 June) POLYPILL: a formulation with a statin, 3 blood pressure lowering drugs each at half standard dose, folic acid (0.8 mg), and aspirin (75 mg) It reduces IHD events by 88% and stroke by 80% One third of people taking this pill from age 55 would benefit, gaining on average about 11 years of life free from an IHD event or stroke

81 ISO Format MENDIS, 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 ISSN WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)

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83 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…

84 Regimens of aspirin, two blood-pressure drugs, and a statin could halve the risk of death from cardiovascular disease in high-risk patients. 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. 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. Developing countries should encourage the use of these inexpensive drugs that are currently available for both primary and secondary prevention.

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89 Is polypill approach feasible and effective in preventing cardiovascular damage? A Polypill for Everything ? Now who's playing God ? BMJ letter from S. Taylor and A. Konings RIGHT or WRONG? The dogs howl, but the moon still keeps on shining BMJ letter from a medical student

90 BMJ 2004; 329: 1447 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)

91 Lifetime effect of Polymeal at age 50 Franco OH et al. BMJ 2004; 329: 1447 Total life expectancyLife expectancy free from CVD Years None Polymeal +6.6 yrs +4.8 yrs +9.0 yrs +8.1 yrs

92 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 tasty alternative for reducing cardiovascular morbidity and increasing life expectancy in the general population.

93 The REACH Study ( pts, 52% donne) Mc Cullough PA JACC 2002;39:60

94 Naylor MD et al.: JAMA, 281,613, pts anziani ( M=75 a.) can varie patologie (60 CHF) ad alto rischio di ricovero INTERVENTO : piano di dimissione articolato visite a casa di infermiere a 2 e 10 gg. contatti telefonici DURATA : 24 settimane RISULTATI : Intervento Controllo Reospedalizzazioni 20.3% (-45%) 37.1% Reosp. multiple 6.2% 14.5% Giorni di ricovero Spesa sanitaria $ 0.6 milioni$ 1.2 milioni Costo/paziente $ 3630$ 6661

95 Gli interventi più efficaci sono quelli capaci di ridurre il numero delle ospedalizzazioni, la lunghezza della degenza ospedaliera (soprattutto in terapia intensiva), di allungare la vita e di migliorarne la qualità. I dati della Letteratura dimostrano che il management ottimale dello scompenso cardiaco congestizio sotto il profi- lo del rapporto costo-efficacia può essere raggiunto attra - verso un approccio multidisciplinare combinato di misure non farmacologiche e di terapia medica massimale. Questo risultato può essere conseguito con un rapporto incrementale costo-efficacia ampiamente nei limiti di accet- tabilità. ( Rich Mw et al.: Arch. Intern. Med. 159,1690,1999)

96 CLINIC OR HOME BASED INTERVENTIONS?

97 Veramente, io ero sicuro che…….

98 some widespread misunderstandings about chronic disease - and the reality Chronic disease epidemic is rapidly evolving Global recognition and response has not kept pace Misunderstandings can be dispelled by the strongest evidence

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

100 Facing illness and deepening poverty

101 Reality: chronic diseases affect men and women almost equally

102 Reality: poor and children have limited choice The next generation

103 Strong et al, Lancet 2005

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107 Burden of disease IMPATTO SULLE CAUSE DI MORTE/ SPERANZA DI VITA Cost effectiveness COSTO/ANNI DI VITA GUADAGNATI Cost benefit DENARO/DENARO Cost utility DALY QALY OGGETTIVO SOGGETTIVO (anni senza disabilità) (anni in buona qualità di vita percepita)

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112 Potential therapeutic strategies to prevent the develoment and/or progression of cardiovascular disease Blood pressure control Glycemic control Lipid lowering Weight loss Combination treatment in a unique polypill?

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114 Fixed Drug Combination for Patients with CHD Low dose antiplatelet (aspirin 75 mg)Low dose antiplatelet (aspirin 75 mg) Full dose of a statin (simvastatin 40 mg)Full dose of a statin (simvastatin 40 mg) Full dose of an ACEI (lisinopril 10 mg)Full dose of an ACEI (lisinopril 10 mg) Half dose of a BB (atenolol 25 mg)Half dose of a BB (atenolol 25 mg) The Polypill?

115 Low dose antiplatelet (aspirin 75 mg)Low dose antiplatelet (aspirin 75 mg) Full dose of a statin (simvastatin 40 mg)Full dose of a statin (simvastatin 40 mg) Full dose of an ACEI (lisinopril 10 mg)Full dose of an ACEI (lisinopril 10 mg) Half dose of a diuretic (HCT 12.5 mg)Half dose of a diuretic (HCT 12.5 mg) The Polypill? Fixed Drug Combination for Patients with CVD

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117 Regimens of aspirin, two blood-pressure drugs, and a statin could halve the risk of death from cardiovascular disease in high-risk patients. 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. 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. Developing countries should encourage the use of these inexpensive drugs that are currently available for both primary and secondary prevention.


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