La ricerca nello scompenso cardiaco acuto: ci sono reali novità?

Presentazione sul tema: "La ricerca nello scompenso cardiaco acuto: ci sono reali novità?"— Transcript della presentazione:

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

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

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

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

9 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)

10 La ricerca sui trattamenti dello scompenso cardiaco acuto
Fallimenti Semidelusioni

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13 A. Mebazaa et al., JAMA 2007, 297:

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

15 A. Mebazaa et al., JAMA 2007, 297: A. Mebazaa et al., JAMA 2007, 297:

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

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18 M.A. Konstam et al., JAMA 2007, 297:

19 M.A. Konstam et al., JAMA 2007, 297:

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

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22 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

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

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

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

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

28 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: GISSI-3: Six-month data. J Am Coll Cardiol 1996; 27: Tavazzi L et al. The Italian survey on Acute Heart Failure. Eur Heart J 2006; 27:

29 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

30 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…

31 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 % 3-7% 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, ,021 MEDLINE citations ( ) ,908 Modified from Am Heart J 2003; 145: S18-25