La ricerca nello scompenso cardiaco acuto: ci sono reali novità? Aldo P Maggioni Centro Studi ANMCO Firenze

L’epidemiologia dello scompenso acuto rimane un problema rilevante senza segni di miglioramento nel tempo

AHF vs CHF outcomes Lee DS, Am. J. Med. 2004

La ricerca sui trattamenti dello scompenso cardiaco acuto Fallimenti Semidelusioni Piccoli successi

Sopravvivenza dei farmaci per lo S.C. grave 1990 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 1998 Xamoterolo Milrinone (PROMISE) Vesnarinone (VEST) Ibopamina (PRIME-2) Pimobendan Flosequinon Epoprostenol (First) Bosentan (REACH-1)

La ricerca sui trattamenti dello scompenso cardiaco acuto Fallimenti Semidelusioni

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

BNP A. Mebazaa et al., JAMA 2007, 297: 1883-1891

A. Mebazaa et al., JAMA 2007, 297: 1883-1891 A. Mebazaa et al., JAMA 2007, 297: 1883-1891

La ricerca sui trattamenti dello scompenso cardiaco acuto Fallimenti Semidelusioni Piccoli successi

M.A. Konstam et al., JAMA 2007, 297: 1319-1331

M.A. Konstam et al., JAMA 2007, 297: 1319-1331

Per cominciare a ragionare più seriamente E’ possibile fare una stratificazione dei rischi affidabile ?

EHS HF II: data collection Patients screened at the emergency area, including cardiac care unit (CCU) or intensive care unit (ICU), as well as on ward facilities (internal medicine or cardiology) 133 participating hospitals: university hospitals (47%) community or district hospitals (49%) private clinics (4%) 30 European countries Recruitment from 21 October 2004 until 31 August 2005

EHFS II: All-Cause in-Hospital Mortality 39.6% 6.6% 5.3% 5.4% n. 3580 pts n. 139 pts n. 2202 pts n. 1239 pts

Univariate analysis: in-hospital mortality by age, SBP and creatinine at hospital entry 12.9% (n. 3441 patients) 10.8% 9.3% 6.4% 5.7% 5.1% 3.4% 3.0% 3.4% <65 65-80 >80 >130 110-130 <110 <1.4 1.4-2.0 >2.0

EHFS II: All-cause in-hospital mortality by strata of risk score Risk score N. of pts 772 743 726 574 305 321

Per cominciare a ragionare più seriamente E’ possibile fare una stratificazione dei rischi affidabile ? Quali end-point e a quali tempi dobbiamo misurarli ?

The lessons learned from trials and registries... All-cause mortality: The lessons learned from trials and registries... Chronic HF ACS Acute HF Opasich C et al. for the IN-CHF Investigators. Am J Cardiol 2000; 86: 353-357 GISSI-3: Six-month data. J Am Coll Cardiol 1996; 27: 337-344 Tavazzi L et al. The Italian survey on Acute Heart Failure. Eur Heart J 2006; 27: 1207-1215

Research in acute HF: Conclusions Morbidity and mortality of patients with acute HF remain unacceptably high Treatment of acute HF continues to remain largely anecdotal without much progress in the last decades Risk stratification with the identification of simple clinical variables seems to be feasible in any clinical setting In any case, the application of risk scores in the real world of acute HF could be limited by: The heterogeneity of this clinical condition The different patho-physiological background The various clinical settings (and doctor profiles) in which patients with AHF are managed Further efforts should be focused on planning research in the field of AHF

What do we need ? Or in other words … everything… Data on the clinical characteristics. Definition, sub-clasification (ST/non-ST ) Data on the exact pathophysiology of each subtype. Better ways to risk-stratify the patients. Treatments to: Reduce Mortality Reduce Morbidity (worsening heart failure?) Rapid and safe symptoms relief Or in other words … everything…

Comparison of decompensated heart failure with acute myocardial infarction Decompensated Acute myocardial Heart failure infarction Hospitalization per year(in US)  1,000,000  1,000,000 In-Hospital Mortality 3-12% 3-7% Readmission rate (60 days) 35% 10% Guidelines for risk stratification No Yes Guidelines for therapy Yes (ESC) Yes No (AHA/ACC) Largest randomized trial 4,133 41,021 MEDLINE citations (1965-2006) 472 33,908 Modified from Am Heart J 2003; 145: S18-25