La gestione della Dimissione Ospedaliera e della Prevenzione Secondaria

Transitional ACS Care: Not missing the steps In Lab Revasc? Other Rx? Pre- Discharge Right meds Right pt Education Hospital ED Admit? CCU? Transfer? 3-Mo Eval Re-assess EF Lipids at goal? On right meds? On right dose? Depression? Other risks addressed? CCU Acute Cath? Tx to Floor? Ref 42 CHAMP Slide 13&15 Talk Points: In-hospital initiation of cardiovascular protective therapy is the best option for optimizing outcomes. As there are approximately 175,000 different outpatient physician practices that provide care for patients at risk or with known atherosclerotic vascular disease, it has been very challenging to develop systems to ensure the implementation of guideline-recommended, evidence-based therapy. Hospitalization presents an important opportunity to implement secondary prevention therapies. There are extensive systems and protocols already in place in hospitals that are an essential part of normal operations. Institution of lipid-lowering therapy in the inpatient setting for patients hospitalized with atherosclerosis has a number of advantages. Measurement of lipid levels can be systematically integrated into the diagnostic testing performed during cardiac hospitalization through the use of preprinted orders and care maps. The structured setting within the hospital can facilitate the initiation of lipid-lowering treatment though the use of physician prompts and reminders such as preprinted order sets, discharge forms, and involvement of other healthcare professionals. Hospital-based initiation of therapy may help to alleviate patient concerns regarding medication tolerability and side effects. Linking the initiation of lipid-lowering medication and other secondary prevention measures to the patient’s cardiac hospitalization conveys the message that this therapy is essential for the prevention of recurrent events and is an essential part of the patient’s long-term treatment. As demonstrated in studies such as CHAMP, hospital-based systems have now been proven to be effective in improving implementation of evidence-based therapy in patients with atherosclerosis. As long-term patient compliance is significantly improved with in-hospital initiation of treatment, this demonstrates that hospitalization can serve as a “teachable moment” for patients and physicians. Ref 42 CHAMP Slides 13, 15, 19 Ref 42 CHAMP Slide 31 Reference: 1. CHAMP website located at http://www.med.ucla.edu/champ. A presentation entitled “Closing the CHS Treatment Gap”.

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

Adjusted Odds Ratio of 30-Day Post-Discharge Readmission In this multinational study, there was variation across countries in 30-day readmission rates after STEMI, with readmission rates higher in the United States than in other countries. However, this difference was greatly attenuated after adjustment for length of stay. Kociol RD, et al. JAMA. 2012;307:66

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

SCA: Punta dell’Iceberg dell’Aterotrombosi Subclinico Persistenza ipereattività Piastrinica Presenza di Placche Coronariche multiple Infiammazione vascolare Clinico Rottura Acuta placca evento: (UA/NSTEMI/STEMI) 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.

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

Statistiche US: Eventi post-SCA Eventi a 5 aa Morte (%) IM ricorrente o CHD fatale (%) Scompenso (%) 40-69 aa M 15 16 7 F 22 12 > 70 aa M 50 24 21 56 25 O’Connor R et al.Circulation 2010

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 Torabi, A. et al. J Am Coll Cardiol 2010;55:79-81

Incidenza di scompenso e disfunzione ventricolare sinistra postinfartuale Frazione di eiezione < 40% = 16% Frazione di eiezione < 45% = 25% IN-ACS Outcome on file Nicolosi GISSI-3 trial Eur Heart J 1996 Killip >1 = 22% Scompenso cardiaco = 20% Di Chiara BLITZ Study Eur Hear J 2003 Steg GRACE Registry Circulation 2004 Dati SDO 2004 90.175 pazienti dimessi dopo infarto miocardico acuto 20.000 con indicazione a riabilitazione cardiologica degenziale

G Ital Cardiol 2011;12 (3):219-229

Documento di consenso ANMCO-IACPR/GICR Criteri di accesso alla riabilitazione cardiologica degenziale Premesse fondamentali Modificazioni dell’epidemiologia clinica dell’ IMA Concetto di “priorità”alla riabilitazione cardiologica Priorità all’alto rischio clinico - Riformulazione dell’offerta delle strutture riabilitative G Ital Cardiol 2011;12 (3):219-229

Gerarchia delle variabili prognostiche utili alla dimissione, percorso assistenziale e timing dei controlli Scompenso cardiaco e/o FE<40%; IM > 1/3 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 2-3-4 --------- Controllo clinico strumentale a 30 giorni CEN ANMCO-GIC 2011

Criteri per la selezione dei pazienti da inviare nei Centri di Cardiologia Riabilitativa Documento di Consenso ANMCO /GICR-IACPR … Il Panel ritiene quindi prioritario l’invio 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

Discharge Form 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 patient’s 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 15

Discharge Protocols Enhance communication with patient and between specialist(s) and primary care physicians Shared targets for improvement High-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

Complemetary tools for HCPs and patients 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 PDFs of the HCP and patient tools are provided in the online toolkit – along with details of how to order hard copy versions for use in your own practice 17

Five steps to optimal post-ACS care Cardiac rehabilitation and ongoing care Lifestyle modification Goal of intervention Therapeutic interventions Integrated communication 18

1. Cardiac rehabilitation and ongoing care 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 19

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 20

Eat a healthy balanced diet4 Consider a Mediterranean-style diet. Increase fresh food intake and reduce processed foods5 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 day7 • Choose wholegrain and high-fibre foods, e.g. wholegrain rice/pasta, wholemeal bread, oats, seeds, nuts, pulses, etc8. • 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 day10. Beware of hidden salt content • Consider foods enriched with plant sterols or stanols, e.g. yoghurt, milk, margarine spreads11 21

Increase physical activity12 Limit alcohol intake12 Drink alcohol in moderation:, women ≤1–2 units/day, men ≤2–3 units/day Increase physical activity12 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 smoke13 Post-MI patients should not smoke Smokers should be offered medication for smoking cessation and referred to local stop-smoking services Manage weight13 Balance energy intake with energy expenditure Advice should be provided to individuals when body mass index (BMI) >25 kg/m2 or those with an increased waist circumference If overweight aim to lose around 0.5 kg/1 lb per week 22

3. Goal of intervention 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 pressure • <130/80 mmHg13 • <125/75 mmHg for patients with chronic kidney disease (CKD)14 Blood sugar • HbA1c <6.5%13 Weight BMI13 • <25 kg/m2 Waist circumference16 • Europids o Male <94 cm o Female <80 cm • South Asians and Chinese o Male <90 cm Key: BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol 23

European Guidelines on Cardiovascular Disease Prevention (Version 2012) Perk J, et al. Eur Heart J doi:10.1093/eurheartj/ehs092

Aspirina – tienopiridine* 20-30% Beta-bloccanti* 20-35% 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 25

Adherence Rates After Discharge for ACS if Therapy is Started In-Hospital 100 92 88 87 80 80 60 Percent of Patients 40 20 ASA -blocker ACEI Statin [11,465/12,463] [6796/7738] [1906/2379] [5522/6320] GRACE Registry: 21,408 patients, multinational, assessment at discharge and 6 months Eagle KA, et al. Am J Med. 2004;117:73-81.

Discharge Medication Use 100% 93% 89% 84% 80% 67% 67% 60% 40% 20% 0% Aspirin β-Blockers ACE Inhibitors* Lipid- Lowering Agent† Clopidogrel *LVEF <40%, CHF, DM, HTN. †Known hyperlipidemia,  TC,  LDL. Q4 2003 CRUSADE data. © 2003 Duke Clinical Research Institute. Used with permission. Available at: http://www.crusadeqi.com.

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

Adherence to statins after two years, by condition TITLE PAGES Title is 40pts. Bullet/paragraph text is 18pts. Largest is 60pts. Jackevicius CA, et al. JAMA 2002;288:462

Why adherence matters “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.” Results of failure to adhere to prescribed medications: Increased hospitalization Poor health outcomes Increased costs Decreased quality of life Patient death TITLE PAGES Title is 40pts. Bullet/paragraph text is 18pts. Largest is 60pts. Benner JS, et al. JAMA 2002;288:455

European Guidelines on Cardiovascular Disease Prevention (Version 2012) Perk J, et al. Eur Heart J doi:10.1093/eurheartj/ehs092

SUI FARMACI CARDIOVASCOLARI OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI L’Osservatorio 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 01/01/2008 31/12/2008 31/12/2009 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

Doppia antiaggregazione Aspirina + Clopidogrel Aspirina + Ticlopidina OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI Terapia I semestre Totale % Aspirina 1.765 33,4% Aspirina + Clopidogrel 2.740 51,9% Aspirina + Ticlopidina 246 4,7% Altra terapia antiaggregante* 456 8,6% Nessuna terapia nel I semestre 75 1,4% 5.282 100,0% N. pazienti: 5.207 Evento indice Doppia antiaggregazione Aspirina Aspirina + Clopidogrel Aspirina + Ticlopidina solo SCA (N=4.250) 1.099 (25,9%) 124 (2,9%) 1.529 (36,0%) SCA + Rivascolarizzazioni (N=2.342) 1.641 (70,1%) 122 (5,2%) 236 (10,1%)

SUI FARMACI CARDIOVASCOLARI OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI Trattati con antiaggreganti nel follow-up: 5.117 N. trattati aderenti nel I e nel II semestre: 3.084 (60,3%) N. trattati aderenti nel I semestre: 3.481 (68,0%)

Aspirin Discontinuation in 50,279 CAD Patients Increased Thrombotic Risks Biondi-Zoccai G, et al. Eur Heart J 2006 27:2667

Premature Discontinuation of Antiplatelet Tx as Predictor of Stent Thrombosis OR=89.8 (29.9-270) HR=19.2 (5.6-65.5) OR=4.8 (2.0-11.1) HR=13.7 (4.0-46.7) 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

Status of Antiplatelet Treatment and Time of Definite DES Thrombosis 4-Year results from a large 2-Institutional (Rotterdam/Bern) cohort study 8146 patients (SES/PES implantation in 2002-2005) 4 100% 12 9 16 Dual Antiplatelet Therapy 87 68 75% 42 Single Antiplatelet Therapy 50% 42 25% No Antiplatelet Therapy 20 0% Early Stent Thrombosis Late Stent Thrombosis Very Late Stent Thrombosis Wenaweser P et al, J Am Coll Cardiol 2008;52:1134 37

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

Discontinuation Causes 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: Surgery 34.5% Bleeding 21% Medical decision 17.6% Dental interventions 7.6% Economic/burocratic reasons 5.9% Anticoagulant therapy 5.0% Rossini R et al. Am J Card 2011, 107: 186

5. Integrated communication Good communication between secondary and primary care, community services and the patient is essential12 Post-ACS hospital discharge summary is vital component of successful communication24 40

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